LIBRARY OF CONGRESS, 

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UNITED STATES OF AMERICA. 



DIPHTHERIA 

Its Nature and Treatment 

9 J (S BY 

C. E. BILLINGTON, M.D. 

• /) 

AND 

Intubation in Croup 



AND OTHER 



ACUTE AND CHRONIC FORMS OF STENOSIS . 
OF THE LARYNX 

BY 

JOSEPH O'DWYER, M.D. 

10 



-^ 



^ 




NEW YORK 

WILLIAM WOOD AND COMPANY 

56 & 58 LAFAYETTE PLACE 

I 




Copyright, 1889. 
WILLIAM WOOD & COMPANY. 



PRESS OF 

THE PUBLISHERS' PRINTING COMPANY, 

157-159 WILLIAM STREET, 

NEW YORK. 



#< 



^ 



PREFACE 



I have been emboldened to offer the present work to the 
Profession by the many gratifying- assurances which I have 
received that my previous writings, which appeared in 1876 
and at several subsequent times, have been of service to some. 
Those writings consisted mainly in statements of my own 
clinical observations and experience. My chief motive in add- 
ing* the present one has been a desire to express my views 
on various important points somewhat more fully than was 
possible in them, and in connection with related facts in the 
history, the etiology, and the pathology of the disease, and 
recent advances in its therapeutics. 

To have made this an exhaustive treatise would have been 
impossible, in view of the great variety of aspects which have 
been assumed by the disease and its complications in occasional 
epidemics and individual cases, the wide diversity of the views 
which have been entertained as to its pathology, and of agents 
and methods which have been employed in its treatment, the 
resulting vastness of the literature relating to it, and the 
limitations of the time and space at my disposal. I have, 
however, endeavored to present a clear and succinct state- 
ment of those facts in existing knowledge which are most es- 
sential to the formation of an intelligent opinion as to its 
nature, and of those therapeutical principles and details, the 



IV PREFACE. 

comprehension and application of which will, as I believe, en- 
able the physician to treat it most successfully. 

It affords me much pleasure that Dr. O'Dwyer has kindly 
consented to treat, in this connection, of that very important 
addition made by him to our therapeutical resources in deal- 
ing- with the most distressing- and fatal form of diphtheria, — 
intubation of the larynx. 

C. E. BlLLINGTON. 
New York, April 15, 1889 



CONTENTS. 



CHAPTER I. 

PAGE 

Definition and History 1 

CHAPTER II. 
Etiology 16 

CHAPTER III. 
Pathology 46 

CHAPTER IV. 
Symptoms 68 

CHAPTER V. 

The Primary Nature of Diphtheria 96 

CHAPTER VI. 
Secondary Diphtheria 104 

CHAPTER VII. 
Diphtheritic Paralysis . . 108 

CHAPTER VIII. 
Diagnosis 121 

CHAPTER IX. 
Prognosis 139 

CHAPTER X. 
Prophylaxis 145 

CHAPTER XI. 
Treatment 150 

APPENDIX. 
Etiology 259 



INTUBATION IN CROUP 

And other Acute and Chronic Forms of Stenosis of the Larynx 265 



DIPHTHERIA; 

ITS NATURE AND TREATMENT. 



CHAPTER I. 

DEFINITION AND HISTORY. 



Diphtheria is a specific disease which occurs sporadically, 
endemically and epidemically, and is contagious and infectious, 
its essential characteristic being an inflammation of mucous 
membranes, or of the surface of wounds and the adjoining in- 
tegument, which tends, by cellular proliferation and degenera- 
tion and by fibrinous exudation, to the formation of a false 
membrane, and also to the production of a poison which, when 
absorbed into the circulation, causes morbid changes in the 
blood and in various organs of the body. 

The name diphtheria was first suggested by Bretonneau, 

who in his earlier publications employed the term diphtherite, 

derived from the Greek dt<pdapa, a membrane, the termination 

ite (err}?) signifying inflammation, and the compound word 

thus admirably describing the " specific phlegmasia" which 

constitutes the local affection; but in his fifth memoir he 

adopted instead from Trousseau the name diphtherie, which, 

without the limiting suffix, more fitly designates the entire 

disease with its train of local and constitutional phenomena. 

The equivalent name, diphtheria, was thence adopted by Dr. 

W. Farr, .Register General of England, and has since been 

universally employed by writers in the English language. 
1 



2 diphtheria; its nature and treatment. 

Although this name and much of the more exact knowl- 
edge of the disease which has accompanied and followed its 
introduction are of recent origin, there is abundant evidence 
that the malady itself has prevailed widely among mankind 
since the most ancient times. In the sixth century B.C. or 
thereabouts, D'havantare, an Indian physician, in his " System 
of Medicine," written in Sanskrit, described the symptoms of 
an incurable disease called " closing of the throat," and " aris- 
ing from phlegm combined with blood," which could hardly 
have been other than diphtheria. 1 The assertion, which has 
been made by some, that the disease is referred to in the 
Hippocratic writings, 2 rests on very inconclusive evidence. 
Asclepiades, in the first century B.C., is said to have performed 
laryngotomy. Aretaeus of Cappadocia, in the first century 
a.d., gives a graphic and unmistakable description of faucial 
and laryngeal diphtheria under the names ulcera JEgyptiaca 
and ulcera Syriaca, which are significant of its wide preva- 
lence. He says that " some ulcers on ths tonsils are mild and 
others are pestilential and deadly." The latter are " exten- 
sive, deep, putrid and coated with white, livid or black concre- 
tions." He then describes the development and extension of 
this form of the disease in the throat and the mouth and as a 
phlegmon on the neck, and its fatal result in "not many 
days," and adds, " But if this malady invades the chest through 
the windpipe, it causes suffocation on the same day." He then 
vividly depicts the symptoms and the struggles which are too 
often witnessed in the later stages of a fatal case of diphthe- 
ritic croup and completes the nosological picture by adding, 
" Children up to the age of puberty are chiefly affected by 
this disease." 3 Galen probably referred to diphtheria when 
he mentioned the expectoration of false membrane from the 

'Quoted in "Diphtheria, its Nature and Treatment," by Morell 
Mackenzie, M.D., p. 14. 

2 Hippocrates : "de Epidemicis," lib. v. cap. iv., and "de Dentitione." 
3 Aretaeus: " De Causis et Signis Acutoruni Morborum," lib. 1 cap. 9. 



DEFINITION AND HISTORY. 6 

pharynx ana the air-passages. 1 Coelius Aurelianus in the third 
century depicted the symptoms of diphtheritic laryngitis and 
also mentioned the imperfect articulation and the regurgita- 
tion of liquids through the nose in swallowing, which result 
from diphtheritic faucial paralysis. 2 Aetius of Amida in the 
fifth century described a disease of children, in which the 
whitish and grayish faucial appearances, the dysphagia, the 
suffocation, the characteristic symptoms of resulting palatal 
paralysis, sudden death after apparent recovery, and intoler- 
ance of too harsh local treatment form a complete clinical 
picture of diphtheria. 3 The probability, from some passages 
in the historians, that severe epidemics of this disease may 
have occurred in antiquity, of which we have no record by 
medical writers, is illustrated by Bretonneau (second memoir) 
in the instance that Macrobius in the year 380 a.d. speaks, 
according to Julius Modestus, of sacrifices which were insti- 
tuted in honor of a heathen goddess, " ut populus Romanus 
morbo qui Angina dicitur, promisso voto, sit liberatus." 

For an interval of more than a thousand years, which con- 
stituted the " Dark Ages/' there is no distinct record of the 
disease, probably not from its non-occurrence, but from a lack 
of competent observers. It is with good reason supposed that 
some of the "plagues" of the Middle Ages may have been 
epidemics of diphtheria. Among these were the pest called 
" esquinancie," a form of angina maligna mentioned in the 
chronicle of St. Denis for the year 580, and a destructive "pes- 
tilentia faucium " at Rome in 856, and another in 1004 recorded 
by Baronius, and a fatal " cynanche " in the Byzantine empire 
in 1037 recorded by Cedrenus, and an angina which carried off 
many children in England in 1389, referred to by Short. 4 

In the sixteenth century records of the occurrence of epi- 

! "De Locis Affectis," lib. 1. cap. 9. 

8 "D'e Acutis Morbis," lib. iii., cap. 2 et cap. iv. 

3 Petrabibl. Sermo viii. , cap. 46. 

4 Cited by Hirsch, Geog. and Hist. Pathol., vol. iii. 



4 DIPHTHEEIA; ITS NATURE AND TREATMENT. 

demies of diphtheria beg-in rapidly to multiply. Among- these 
an epidemic in Holland in 1557 was described by Peter Forest l 
as an " angina malig-na contagiosa," rapidly fatal b}^ strangu- 
lation, and another in 1564 and 1576 mentioned by Van Wier 2 
as an " angina maligna," particularly common among children 
and fatal in from one to seven days; others occurred in the 
Rhenish provinces and in North Germany, and one in Naples 
and Sicily. An epidemic in Paris in 1576 was described by 
Baillou, 3 who mentioned false membrane as observed in an 
autopsy: " Pituita lenta contumax quae instar membranae cu- 
jusdam arteriae asperse erat obtenta." 

In Spain a great epidemic, or succession of epidemics, of 
angina maligna, there known under the popular name of gar 
rotillo, raged from 1583 to 1618, and was well described by a 
number of medical writers. Beginning in Seville in the former 
year, it reached its widest diffusion over the country about 1610, 
and in 1613 the mortality was so frightful that that year has 
since borne the name of "anno de los garrotillos." Among 
the best descriptions of the disease were that of Villa Real, 4 
who minutely described false membrane as seen by him, not 
only in many cases during life, but also in autopsies; that of 
Herrera, 5 who also observed diphtheritic false membrane in 
autopsies, and described diphtheria of the skin and of wounds ; 
that of Mercado, 6 physician to Philip II. and Philip III., who 
noted the slight degree of fever present in some very grave 
cases, described diphtheritic cervical adenitis, and mentioned 
an instance of a child communicating the disease to its father 

^'Observat. et Curat. Medic." lib. vi., observ. ii., schol. Lugd. Bat., 
1591. 

2 Van Wier : Observat. lib. i, sec. 3. 

3 Epidenriorurn, lib. ii., Genev. 1762. 

4 Villa Real : " De Signis Causis, Essentia, Prognostico et Curatione 
Morbi Suffocantis," Compluti 1611. 

5 " De Essentia, Causis, Notis, Presagio, Curatione et Precautione 
Morbi Suffocantis Garrotillo Hispane Appellati," auctore Doctore 
Herrera, Matriti, 1615. 

6 Consult, med. lib. cons, xiv., in opp. Frankf. 1620. 



DEFINITION" AND HISTORY. 5 

by biting- his finger; and of Heredia, 1 physician to Philip IV., 
who distinguished the two forms of the disease, the suffocative 
and the asthenic, observed paralysis of the palate, the pharynx 
and the limbs, believed in a secondary infection by the resorp- 
tion of morbid products, and recommended for its prevention 
the early employment of cauterization. 

An epidemic in Portugal in 1626 is described by Bar- 
bosa. 2 

In Italy malignant sore throat, having been prevalent in 
Mantua and Lombardy in 1610, 3 broke out in the city of Naples 
in 1617, gradually overran the kingdom of the Two Sicilies 
and the States of the Church, and prevailed in various epi- 
demics and recurrences in many parts of Italy until 1650. 
Among the accounts of these epidemics are that of Sgambatus, 4 
Carnevale, 5 Aetius Cletus, 6 who vividly described not only 
pseudo-membrane in the fauces, but the gangrenous, the laryn- 
geal, the toxgemic, the asthenic, and the nasal forms of the 
disease, and also the protracted debility and the paralysis of 
the vocal organs of those who recovered; and Severino, 7 who 
described diphtheritic membrane as seen in an autopsy, and 
diphtherial paralysis. 

In the eighteenth century angina maligna was even more 
prevalent than in the seventeenth, occurring in nearly every 
country of Europe and in some portions of America. Many 
localities in Spain and Portugal were invaded by it between 
the years 1701 and 1786. It prevailed in Paris and in many 
other towns in France in 1743-50; again in Paris in 1758-9 and 
in 1762. The first of these epidemics was described by Marteau 



1 " De Morbis Acutis," lib. ii., sec. iii., cap. 5. Lyon, 1685. 
2 " Estudios sobre o garrotilho ou croup." Lisbon, 1861. 
3 Corradi "Annali delle Epidemie occorse in Italia," iii. 16. 
4 "De Pestilente Faucium Affectu, Neapoli Saeviente Opusculum," 
auctore Andrea Sgambato. Neapoli, 1620. 

5 " De Epidemico Strangulators Affectu," etc. Neapoli, 1620. 
6 " De Morbo Strangulators opus." Romse, 1636. 
7 " De Pedauchone Maligna," etc. Neapoli, 1643. 



\ 



ITS NATUEE AND TREATMENT. 

de Grandvilliers, 1 and by Chomel, 2 who accurately described 
paralysis of the soft palate, and a case of diphtheritic strabis- 
mus. Epidemics occurred in various portions of Italy between 
1747 and 1786. One which prevailed in Palermo in 1747-8 was 
described by Ghisi, 3 who observed laryngeal croup and pharyn- 
geal angina gangrenosa as each occurred separately, and when 
both were united in the same patient, and noted the phenom- 
ena of diphtheritic paralysis. Epidemic outbreaks occurred 
in Holland between 1745 and 1770. In Great Britain an epi- 
demic of angina maligna, was described in 1713 by Dr. Patrick 
Blair, 4 under the name of "the croops" as "universal" at 
Coupar Angus. In 1748 a fatal outbreak in London of scar- 
latina anginosa, which was complicated with diphtheria, was 
described by Dr. Fothergill. 5 In 1745-8 a "morbus strangula- 
torius," which presented the characteristic features of malig- 
nant diphtheria, prevailed in Cornwall, and was described by 
Starr. 6 

In 1765 appeared the treatise on croup by Francis Home 
of Scotland. 7 This work is very important, not only from the 
completeness of its descriptions and the logical force of its de- 
ductions, but also from the fact that it, for the first time, 
clearly depicts a form of pseudo-membranous disease which 
was regarded by him and has since been regarded by many 
others as distinct from diphtheritic angina. According to 
him croup, or, as he names it, " suffocatio stridula," is a dis- 
ease which " belongs peculiarly to children." It " has a local 

1 " Dissertation Historique sur l'espece de Mai de Gorge Gangr6neux 
qui a i'6gn6 parmi les Enfants Fannie derniere." Paris, 1749. 

2 "Dissert. Hist, sur l'aspect du Mai de Gorge Gangr6neux, " etc., 
Paris, 1749. 

3 " Lettere Mediche del Dottore Martino Ghisi." Cremona, 1749. 

4 " Observations in the Practice of Physic," etc. London, 1713. 

5 "An Account of the Sore Throat Attended with Ulcers," by Dr. 
John Fothergill. London, 1748. 

6 " Philosophical Transactions," 1750, t. xlvi., p. 435. 

7 "An Inquiry into the Nature, Causes and Cure of Croup," by Fran- 
cis Home, M.D. Edinburgh, 1765. 



DEFINITION AND HISTOEY. 7 

situation," being- "seldom found at any great distance from 
the sea-shore/' though " very wet and marshy situations some- 
times produce it." Its occurrence is also favored by cold and 
damp weather, and recent attacks of measles, whooping-cough 
or small-pox predispose to it. It is "a disease of an inflam- 
matory nature," which " appears to be confined chiefly to the 
trachea, as the patients have no pain in deglutition, and as the 
fauces are at most but a little redder." " The place first and 
most particularly affected is the upper part of the trachea, 
about an inch below the glottis." " The cause of this disease 
is a preternatural white, tough, thick membranous crust cov- 
ering often for many inches the inside of the trachea." " This 
membrane is not attached to the parts below, but is easily 
separated from them, as there is always matter behind it." 
There are two forms of the disease, " the inflammatory and 
less dangerous, and the less inflammatory and highly danger - 
ous." This description is based on twelve cases, of which 
three were of the former or catarrhal variety, and terminated 
in recovery, and are given as examples of those which are 
"common." The other nine were fatal ones, and in all of these 
autopsies were made, the membrane as above described being 
found in every one. In only one, which he regarded as com- 
plicated with " angina," the throat and tonsils were inflamed 
and " covered with mucus." There is no mention of an epi- 
demic character nor of contagiousness in the disease described, 
but it is possibly worthy of note that two of the fatal cases 
(IV. and V.) were those of a brother and sister, the former 
having been attacked September 29th, 1760, the latter, Octo- 
ber 5th. The treatment he advises consists of blood-letting, 
blisters, emollient fomentations and cataplasms around the 
neck, inhalation of the steam of water and vinegar, and gentle 
sudorifics. Emetics he had not found useful. When the mem- 
brane has formed he recommends bronchotomy. 

Diphtheria again prevailed in London and in some other 
localities in England in 1790-1793. 



8 diphtheria; its nature and treatment. 

Epidemics occurred in Germany in 1752, 1755 and 1790. In 
1778 Michaelis 1 in Gottingen wrote in confirmation of the de- 
scriptions and views of Home. The disease prevailed in the 
Simmenthal, Switzerland, in 1752, and in many places in 
Sweden in the years 1755-62. In the latter country Wilcke in 
1757 described pseudo-membranous angina. 2 

In New England an epidemic occurred in 1735, which was 
described by Dr. William Doug-las 3 as originating in Kings- 
ton township, about fifty miles eastward of Boston, and after 
prevailing with great fatality in the surrounding country, at 
length reaching Boston, where it was much milder. The 
symptoms of this malady, which are fully detailed, are clearly 
those of scarlatina, but in many instances there was evidently 
a complicating or secondary diphtheria. 

Two years later a similar epidemic is described in a letter 
from Eev. J. Dickinson, 4 dated " Elizabeth Town, New Jersey, 
February 20, 1738-9," as having occurred in that place some 
time previously, a portion of which description is so vivid as 
to be worthy of quotation. He describes the disease in six 
forms, the first being evidently scarlatina, or possibly in some 
cases measles. The second form " frequently begins with a 
slight indisposition, much resembling an ordinary cold, with a 
listless habit, a slow and scarce discernible fever, some sore- 
ness of the throat and tumefaction of the tonsils; and perhaps 
a running of the nose, the countenance pale and the eyes dull 
and heavy. The patient is not confined, nor any danger a/p- 

1 " De Angina Polyposa Menibranacea. " Gottingen, 1778. 

2 "Diss. Med. de Angina Infantum." Upsala, 1764. 

3 "The Practical History of a New Epidemical Eruptive Miliary 
Fever with an Angina Ulcusculosa which prevailed in Boston, New 
England, in the years 1735 and 1736. Printed and Sold by Thomas 
Fleet. 

4 " Observations on that Terrible Disease, Vulgarly called the Throat- 
Distemper, with Advices as to the Method of Cure." In a Letter to a 
Friend. By J. Dickinson, A.M. Boston: Printed and Sold by S. Knee- 
land and T. Green in Queenstreet over against the Prison, 1740." Jon- 
athan Dickinson was the first President of Princeton College and the 
first pastor of the Presbyterian church of Elizabeth, N. J. 



DEFINITION" AND HISTORY. 9 

prehended for some days, until the fever gradually increases, 
the whole throat and sometimes the roof of the mouth and 
nostrils are covered with a cankerous crust, which corrodes 
the contiguous parts and frequently terminates in a mortal 
gangrene. When the lungs are thus affected the patient is 
first afflicted with a dry, hollow cough, which is quickly suc- 
ceeded with an extraordinary hoarseness and total loss of the 
voice, with the most distressing asthmatic symptoms and 
difficulty of breathing, under which the poor miserable creat- 
ure struggles until released by a perfect suffocation or stop- 
page of breath. This last has been the fatal symptom under 
which the most have sunk that have died in these parts. All 
that I have seen to get over this dreadful symptom have by 
their perpetual cough expectorated incredible quantities of a 
tough whitish slough from their lungs." 

Dr. Cadwallader Colden 1 traces the progress of the epi- 
demic from Kingston westward, it appearing " first in those 
places where the people of New England chiefly resorted for 
trade, and in the places through which they travelled " until 
it "spread over all the British colonies in the Continent," 
"children and young people" being "only subject to it; " but 
he adds nothing of importance to the two descriptions of the 
disease just quoted. 

In 1771 appeared the classical treatise of Dr. Samuel Bard 2 
of New York, who described with clearness and accuracy 
pharyngeal, laryngeal and cutaneous diphtheria, occurring 
separately and in the same patients, from clinical observation 

1 " Extract of Letter from Cadwallader Colden, Esq., to Dr. Fothergill 
concerning the Throat Distemper," dated Coldenham in New York, 
1753. Published in London Observations and Inquiries, vol. i., p. 211. 

2 "An Enquiry into the Nature, Cause and Cure of the Angina Suffo- 
cativa or Sore-Throat Distemper as it is commonly called by the In- 
habitants of this City and Colony. By Samuel Bard, M.D., and Pro- 
fessor of Medicine in King's College, New York. Printed by S. Inslee 
and A. Car, at the New Printing-Office in Beaver Street, MDCCLXXI." 
Reprinted in Transactions of the American Philosophical Society, 
Philadelphia, 1789. 



10 diphthekia; its nature and treatment. 

and post-mortem examination, as pseudo-membranous but not 
gangrenous affections, and believed that these various forms 
of disease, with those described by the Italian writers and by 
Home, Fothergill, Huxham and Douglas, were essentially re- 
lated and "arise from the same leaven. " He also described 
consecutive paralysis affecting deglutition, speech and locomo- 
tion, and emphasized the infectiousness of the disease and the 
importance of isolating the sick. 

Although the masterpiece of Bard has in recent times been 
appreciated at its true value, it does not seem to have com- 
manded the contemporaneous attention which it merited, and 
the ideas of Home maintained their ascendancy. 

Their influence is illustrated in a "letter on the croup " 
from P. Middleton, 1 M.D., to Mr. Richard Bayley, surgeon, 
New York, dated New York, November 30, 1780. He says, 
"When I first came (from Scotland) to this city in 1752,1 
found complaints of the throat not infrequent, but most of 
them were usually considered as having a malignant tendency 
if not actually anginse gangrenosa?, and in consequence of this 
general belief antiseptics were the remedies used in preference 
to all evacuants except perhaps emetics." He proceeds to 
state his belief that croup is " totally distinct from malignant 
sore throat/' and asserts that though the two affections may 
be united, he has never seen such an instance. 

Similar views appear in a letter on the croup from Professor 
Richard Bayley 2 to William Hunter, M.D., London, published 
about 1781. He quotes with approval the post-mortem obser- 
vations of Bard, but regards angina trachealis as an " inflam- 
matory " affection, and, like Dr. Middleton, has treated it suc- 
cessfully, even in its advanced stages, by the vigorous employ- 
ment of venesection, blisters, mercurial evacuants and emetics. 

Dr. John Archer, 3 in a letter to Benjamin Smith Barton, 

1 Medical Repository, New York, vol. xiv., p. 347. 

2 Medical Repository, New York, vol. xii., p. 331, and vol. xiv., p. 345. 
8 Medical Repository, New York, vol. ii. p. 27. 



DEFINITION AND HISTORY. 11 

M.D., of Philadelphia, dated Hartford County, Maryland, 
March 17, 1798, likewise considers croup as a "topical disease, 
confined to the trachea arteria, and the several ramifications 
thereof/' 

In France, also, at this period most writers held the same 
views regarding" the distinct nature of croup and angina ma- 
ligna. 

Several members of the imperial family having died of the 
former disease, a prize was offered by Napoleon I. for the best 
essay upon it. This prize was divided between Jurine, of 
Geneva, and Albers, of Bremen. Jurine recognized the fact of 
the frequent concurrence of croup with angina gangrenosa, 
and expressed doubt as to the actual existence of gangrene in 
the majority of cases of the latter disease. 

At length appeared the writings of Bretonneau, which may 
be said to have founded on a firm and broad basis the modern 
knowledge of diphtheria. Many of the facts which he an- 
nounced respecting the disease had, as we have seen, been 
previously observed and stated by others. It was his glorious 
achievement to establish them by incontrovertible demonstra- 
tion and to present them in their true relations. The principal 
writings of Bretonneau x consist of five papers or memoirs, the 
first two of which were read at the Academie Royale de Mede- 
cine in 1821 ; the last was published in 1855. His studies of the 
disease were principally made in three great epidemics, that 
of Tours in 1818, de la Ferriere in 1825, and Chenusson in 1826. 
The most distinctive feature of Bretonneau's work was the 
great amount of necroscopic research which it comprised, 
sixty autopsies being referred to in the first epidemic alone. 
Among the most important points established by his observa- 
tions were the absence of gangrene in most cases of diphtheria, 

1 " Des inflammations speciales du tissu muqueux et en particulier de 
la diphtbeYite, ou inflammation pelliculaire connue sous le nom de 
croup, d'angine maligne, d'angine gangreneuse, etc., Paris, 1826.'" 
" Sur les moyens de prevenir le developpement et les progres de la 
diphtheric " Archives Grenerales de M6decine, 1855. 



12 diphtheria; its nature and treatment. 

the nature and the relations of pseudo-membrane, its frequent 
continuity and its essential unity in the buccal, the naso- 
pharyngeal and the laryngotracheal regions, the specificity 
of the diphtheritic inflammation in distinction from the catar- 
rhal and from other specific phlegmasia, the non-identity of 
membranous and "spasmodic" croup, and the true relation of 
sequence and causation between the local and the constitu- 
tional phenomena of diphtheria, which he expressed in the 
phrases, " localized primitive diphtheria " and " the secondary 
or constitutional affection." x 

The teachings of Bretonneau were ably seconded and am- 
plified by various writers, among the earliest of whom were 
Guersant, 2 Louis, 3 Gendron 4 and Mackenzie, 5 the two latter of 
whom were among the earliest advocates of the topical use of 
nitrate of silver. 

During the earlier half of the present century the prev- 
alence of diphtheria greatly diminished, except in France 
where numerous epidemics occurred between 1810 and 1843, 
and again from 1816 to 1855. In other European countries 
and on this continent it was either unknown or occurred only 
sporadically or in occasional and limited epidemics. In 1856, 
an outbreak having occurred at Boulogne, in France, which 
was especially fatal among the resident English, the disease 
was conveyed to England and prevailed there in numerous 
and fatal epidemics until 1863. At about the same time a new 
and more general outbreak than had ever before occurred 
began not only in Europe and America, but also in Asia, 
Africa, Australia and Polynesia; and that general prevalence 
of the disease has since continued, though often in a greatly 

1 Fifth Memoir. 

2 Dictionnaire de Medecine, Articles "Angine Couenneuse," t. ii., 
" Croup," t. vi., and " Stomatite Couenneuse," t. xix. 

3 " Du Croup consider^ chez ladulte," Arch. Gen., t. iv., pp. 1 and 369. 

4 " Observations sur une Angine Couenneuse," Journal Compl^men- 
taire du Diction, des Sciences Med., t. xxiii., p. 346. 

5 "On the Symptoms and Cure of Croup," Edin. Med. and Surg. 
Journ., vol. xxiii., p. 294. 



DEFINITION AND HISTOKY. 13 

mitigated form, until the present time, so that in most of the 
cities of the world at the present day diphtheria contributes a 
considerable annual quota to the list of mortality. 

Under these circumstances it is not surprising- that the 
literature of the disease has assumed enormous proportions, 
and is less and less occupied with accounts of particular epi- 
demics and more and more with questions relating to etiology, 
pathology, and therapeutics. 

As various writers will necessarily be referred to in the 
chapters on these subjects, but few additional ones need now 
be enumerated. Deslandes, in 1827, 1 in considering the ques- 
tion of the identity of pseudo-membranous angina and croup, 
gave a minute and valuable historical review of the subject of 
epidemic sore throat. His views on the question referred to 
accord affirmatively with those of Bretonneau. The doctrine 
that diphtheria is a primarily constitutional affection was 
advocated by Emangard, 2 who attacked the views of Breton 
neau from the point of view of the "physiological" school, 
maintaining that the disease is of malarial origin and of kin- 
dred nature to typhus — a " gastro-enteric angina." Fuchs 3 
also, after a historical review of the subject, held that angina 
maligna was a " typhus " identical with the pulpous form of 
hospital gangrene. 

Both of these questions, namely that of the identity or di- 
versity of membranous croup and diphtheria and that of the 
primarily local or constitutional nature of diphtheria, have 
since been discussed by many waiters from opposite points of 
view, representing a diversity of opinion which continues to 
the present day. 

Trousseau, 4 the friend and pupil of Bretonneau, was his 

Journal des Progres des Sc. Med., t. i., p. 152. 

2 " Examen Critique du Traite" de la Diphtherie par M. Bretonneau." 
Paris, 1829. 

3 " Historische Untersuchungen tlber Angina Maligna und ihr Ver- 
haltniss zu Scarlach und Croup." Wtirzburg, 1828. 

4 "Memoir sur une epidemie d'Angine Couenneuse Scarlatineuse, " 



14 diphtheria; its nature and treatment. 

worthy continuator, and supplemented his work by adding- 
from 1829 to 1858 observations which were necessary to the 
complete description of diphtheria, especially in reference to 
its cutaneous form and its constitutional manifestations, in- 
cluding- albuminuria and the various forms of resultant paral- 
ysis. Trousseau was, moreover, like Bretonneau, a warm ad- 
vocate of tracheotomy, and devoted much attention to perfect- 
ing- its method and details. The statement of Bretonneau that 
diphtheria is never accompanied by true gangrene, was shown 
to be subject to many exceptions by Trousseau and also by 
Becquerel, 1 Rilliet and Barthez, 2 and Simon. 3 

The occurrence of albuminuria in connection with diphtheria 
was first discovered in 1857 by Dr. W. F. Wade, 4 of Birming- 
ham, and was soon after independently observed by Dr. Ger- 
main See, of Paris. 5 

Diphtheritic conjunctivitis was first elaborately treated of 
by Yon Graefe 6 in 1857. His publication was closely followed 
by that of Prichard. 7 

The first important publication on the subject of diphthe- 
ritic paralysis was that of Maingault. 8 

The first precise description of the anatomical distinctions 
between the different forms of inflammation of mucous mem- 
branes by Yirchow in 1847, and the first announcement of the 
discovery of a supposed bacterial cause of diphtheria by Lay- 
Arch. Gen., t. xxi., p. 541 ; " De la Diphtherite Cutanee," ibid., t. xxiii., p. 
383; " Lecons Cliniques sur les Angines," Gaz. des Hop., Nos. 86, 89, 100, 
104, 109, 115, 119, etc. 

^'Relation d'une Epid6mie d' Affections Pseudo-membraneuses et 
Gangr6neuses qui a regne a l'Hopital des Enfants," Gaz. Med., Nos. 43, 
44, 45, 46. 

2 " Maladies des Enfants," t. i., pp. 285, 316. 

3 Considerations sur l'Angine Gangreneuse et de son traitement, " 
Bull, de Therap., t. xxiv., p. 401. 

4 Midland Quarterly Journal of the Medical Sciences, April, 1858. 

5 Union M<5dicale, 1858, p. 497. 
6 Archiv. f. Ophthal., b. 1, s. 168. 
'British Med. Journ., 1857, p. 981. 
8 These de Paris, 1854. 



DEFINITION AND HISTORY. 15 

cock in 1858, and many important subsequent pathological 
and etiological investigations by others, will be more appro- 
priately referred to elsewhere in this work. 

In treatment, hydrochloric acid, alum, and later nitrate of 
silver, were locally employed by Bretonneau, and in some cases 
mercury internally. Tonics were advocated by Becquerel 1 in 
1843; alkaline treatment by Baron 2 in 1851; chlorate of po- 
tassa by A. Smith 3 in 1855; iodine by Lecointe, 4 and bromine 
by Ozanam 5 in 1856; muriated tincture of iron internally by 
Heslop in 1858 ; 6 iron and chlorate of potassa by Kingsford; 7 
sulphur by Duche 8 in the same year, and turpentine by Perry 9 
in 1859. 

A method of intubation of the larynx having been devised 
and warmly advocated by Bouchut, a report on the subject 
was presented to the Academie de Medecine by Trousseau in 
1858, so unfavorable that the procedure was condemned by 
the general verdict of professional opinion, was abandoned by 
its author, and fell into such oblivion that when Dr. Joseph 
O'Dwyer, of New York, a quarter of a century later, invented 
and perfected the method of intubation which has rapidly won 
acceptance among the great therapeutical improvements of 
the age, he did so in ignorance of the fact that his idea had 
been anticipated. 

1 Op. cit. 

2 Gazette MeU, 1851, p. 524. 

3 Dublin Hosp. Gazette, vol. ii., p. 149. 

4 Bulletin de Th<3rap., t. i., p. 70. 

5 Comptes Rendus de TAead. des Sci., t. xlii., p. 102, and Mon. des 
Hop., p. 551. 

6 Med. Times and Gazette, vol. xxxvii., p. 552. 

' Lancet, 1858, p. 484. 

8 Gaz. des Hop., Nos. 125 and 133. 

9 Med. Times and Gaz., vol. xxxix., p. 245. 



CHAPTER II. 



ETIOLOGY. 

The causes of diphtheria are not fully known. The knowl- 
edge which we have respecting" them is derived from the ob- 
servation of the circumstances under which the disease 
naturally occurs, the results of experiments for its artificial 
production, and certain facts in its pathology. 

Among the circumstances which ordinarily influence the 
occurrence of diphtheria, one of the most noteworthy is that 
of age. While no period of life is absolutely exempt from its 
attacks, it is in the great majority of cases a disease of child- 
hood. Among nearly 70,000 fatal cases comprised in the re- 
turns of the Registrar General of England, and analyzed by 
Dr. Thursfield, 1 the numbers per thousand of the different 
ages were as follows: — 



nder 1 year, . 








90 


mm 1 to 5 years, 








450 


5 " 10 " . 








260 


" 10 " 15 " . 








90 


" 15 " 25 " . 








50 


" 25 " 45 " . 








35 


45 years and upwards, 








25 



The following table, compiled from the records of the Board 
of Health, shows the ages in 14,688 fatal cases of diphtheria 
which occurred in this city during the ten years, 1873-1882. 
It will be seen that over eight per cent, of all were under one 
year, over seventy-three per cent, of all under five years, and 
over ninety-five per cent, of all, under ten years. 

1 London Lancet, August 3, 1878. 



ETIOLOGY. 



17 



Under 1 year of age, . 

Over " " " and under 5, 

Total under 5, 
Over 5 years and under 10, 

Total under 10, . 
Over 10 years and under 15, 



1,214 

9,622 

10,836 

3,212 

14,048 

311 

87 

53 

37 

34 

28 

25 

16 

12 

12 

8 

3 

6 

6 



2 

14,688 

In some local outbreaks of diphtheria, however, of excep- 
tional malignancy, the proportion of adults affected has been 
much greater. 

The reason of this comparative defencelessness of children 
against the invasion of diphtheria is doubtless mainly the 
softness and delicacy of their mucous membranes, which are 
consequently especially susceptible to irritating influences, 
penetrable by morbific poisons, and liable to inflammatory 
affections in general. 

Diphtheria occurs by marked preference in connection with 
various pre-existing diseases, especially those which produce 
inflammation, erosion or ulceration of the mucous membranes 
of the outer air-passages. 



15 


a 


a 


a 


20, 


20 


a 


a 


it 


25, 


25 


a 


a 


a 


30, 


30 


a 


a 


a 


35, 


35 


a 


a 


a 


40, 


40 


a 


a 


a 


45, 


45 


a 


a 


a 


50, 


50 


a 


a 


a 


55, 


55 


a 


« 


a 


60, 


60 


a 


« 


a 


65, 


65 


a 


a 


a 


70, 


70 


«. 


a 


a 


75, 


75 


a 


(( 


a 


80, 


80 


it 


a 


a 


85, 


85 


a 


a 


a 


90, 


Total . 


. 


. 


. 



18 diphtheria; its nature and treatment. 

For similar reasons the invasion of the skin by diphtheritic 
inflammation is rendered practicable by the removal of the 
epidermis by wounds, blisters, etc. 

Diphtheria occurs by preference in some persons through 
individual or family predisposition. Some instances of great 
mortality in families which have been cited by authors in sup- 
port of this statement were probably merely illustrations of 
the action of intense endemic influences, but I have known in- 
dividuals and families of children to suffer from repeated 
attacks of the disease in the apparent absence of such influ- 
ences, in several successive places of residence, and when 
others living in exactly the same conditions were exempt. 

One attack of diphtheria affords a temporary immunity 
from subsequent ones; but this is usually, at least, of com- 
paratively short duration. Second attacks of diphtheria after 
an interval of a year or more are not uncommon. The sever- 
ity of recurrences of the disease does not seem to differ in any 
way from that of primary attacks. 

Diphtheria occurs under the most widely varying- condi- 
tions of climate, temperature and season, being dependent 
upon none; but its occurrence is nevertheless favored by cold 
and dampness. 

In support of the former assertion it may be stated that 
diphtheria prevails in tropical countries, such as Tunis, Algiers, 
Egypt and the East Indies, as well as in Iceland and Labra- 
dor; during periods of drought as well as of humidity; in 
summer as well as in winter. 

The other assertion, viz., that the occurrence of diphtheria 
is as a general rule favored by cold and by humidity, is proved 
by the fact that it is more prevalent in those regions and at 
those seasons of the year in which those conditions are in the 
ascendant. In reference to its occurrence in different climates, 
Hirsch says, 1 " Its predominance in the temperate and cold 
zones compared with its rarity in the equatorial and sub- 

1 Op. cit. p. 100. 



ETIOLOGY. 



19 



tropical regions is great enough to be significant, even if we 
assume that those differences are only in part real and in part 
to be accounted for by the defective data from countries of 
the latter class.'' 

With reference to seasons of the year he states, " In 124 
epidemics of which we have exact data in regard to their dura- 
tion, all of them being closely circumscribed in place and of 
no more than a few months' continuance, the outbreaks 
reached their height as follows : 

32 in the spring. 
24 " summer. 
30 " autumn. 
38 " winter/' 

Of 18,688 fatal cases which occurred in this city in the 
thirteen years from January 1, 1874, to December 31, 1886, 
according to the records of the Board of Health, 10,769 oc- 
curred in the half years beginning with October, and 7,919 in 
those beginning with April. The distribution by months is 
shown in the following table: 



Years 


Jan. 


Feb. 


M'ch. 


April. 
115 


May. 


June. 


July 


Aug. 

103 


Sept. 


Oct. 


Nov. 


Dec. 


Yearly 
Totals. 


1874 


140 


97 


Ill 


102 


99 


109 


108 


201 


251 


229 


1,665 


1875 


232 


196 


180 


189 


165 


195 


167 


147 


175 


206 


210 


267 


2,329 


1876 


274 


242 


209 


158 


186 


130 


81 


79 


68 


103 


102 


118 


1,750 


1877 


72 


70 


84 


79 


67 


50 


56 


53 


85 


111 


116 


108 


951 


1878 


132 


94 


105 


90 


81 


72 


50 


47 


55 


75 


101 


105 


1,007 


1879 


97 


69 


58 


36 


46 


46 


32 


39 


30 


71 


76 


71 


671 


1880 


72 


77 


65 


81 


76 


61 


89 


97 


125 


199 


234 


214 


1,390 


1881 


212 


160 


180 


164 


190 


209 


197 


173 


173 


203 


178 


210 


2,249 


1882 


218 


169 


181 


154 


156 


133 


95 


78 


63 


88 


97 


93 


1,525 


1883 


104 


87 


88 


92 


92 


82 


66 


73 


62 


82 


81 


100 


1,009 


1884 


79 


82 


73 


77 


83 


92 


70 


.62 


55 


127 


139 


151 


1,090 


1885 


108 


121 


121 


115 


102 


115 


101 


71 


87 


87 


122 


175 


1,325 


1886 


155 


149 


134 


124 


142 


130 


133 


104 


85 


165 


288 


218 


1,727 


M'thly 

Totals. 


1,895 


1,613 


1,589 


1,474 


1,488 


1,414 


1,246 


1,126 


1,171 


1,618 


1,995 


2,059 


18,688 



Cold and dampness undoubtedly favor the occurrence of 
diphtheria mainly as predisposing causes, by their tendency 
to excite catarrhal affections, the relation of which to diph- 
theria has already been referred to. 



20 diphtheria; its nature and treatment. 

A relation of cause and effect between conditions of soil and 
situation and the occurrence of diphtheria is asserted by some 
authorities and denied by others. Hirsch 1 presents an accu- 
mulation of testimony from observers in different countries to 
the effect that the development and epidemic diffusion of the 
disease are absolutely independent of such conditions, the evi- 
dence showing" that high and low, dry and damp situations 
and all geological formations have been equally the seat of its 
prevalence, and that the instances in which it has preferred 
low, damp, and ill-drained locations are fully offset by others 
in which it has apparently made the opposite choice. 

The full acceptance of these facts is, nevertheless, not in- 
consistent with the view that local dampness does favor the 
occurrence of diphtheria. 

Dr. N". M. Thursfield, whose careful attention to this sub- 
ject, and exceptional opportunities for observation in his ca- 
pacity as Health Officer of a district comprising a large urban 
and rural population, entitle his views to the most respectful 
consideration, says : 2 

"While I believe that no very close connection can be 
traced between the incidence of diphtheria and what are 
broadly known as geological formations, there is the closest 
connection between certain conditions of subsoil and situation 
of the house, and the disease. Whatever promotes dampness 
of habitation, the result is the same. 

" M. Trousseau appears to have formed his opinion that the 
disease had no connection with local surroundings, from the 
fact that he had seen it raging equally on low undrained local- 
ities and on breezy heights, I have been called upon on sev- 
eral occasions to investigate outbreaks of diphtheria on ele- 
vated open localities, and have invariably found the same 
condition of dampness of habitation, caused by faulty con- 
struction of the houses in localities where there was a stagna- 



1 Op. cit. p. 104. 

2 London Lancet, August 10, 1878. 



ETIOLOGY. 21 

tion of water, either from a flat table-land with an impervious 
sub-soil, or, more frequently, from the locality being" the divi- 
sion of a water-shed, which is always a cause of stag-nation of 
water." 

Diphtheria, as a general rule, prevails with greater fatality 
in rural regions than in cities. This fact, which has been noted 
in the history of many epidemics, is illustrated by Dr. Thurs- 
field 1 in tables which show a much larger percentage of deaths 
from diphtheria to population in ten rural counties than in ten 
principal cities of England throughout a series of years. Dr. 
Thursfield remarks, " Whatever conditions seem to favor fun- 
goid growth would seem to favor the incidence and persistence 
of diphtheria, and the explanation of the comparative freedom 
of towns from the disease may be the presence of something 
in their atmosphere inimical to such growth." 

May not a partial explanation, however, be found in the 
fact that the inhabitants of cities are, upon the whole, better 
sheltered from the inclemencies of the weather and less ex- 
posed to te dampness of habitation " than those of the country? 

Diphtheria may occur independently of insanitary condi- 
tions. Indeed in some epidemics it has seemed to find most of 
its victims in circumstances where the action of such causes 
could least be suspected. There is, nevertheless, abundant 
evidence that its occurrence is favored by them. The instances 
of its outbreak and prevalence in the country in direct connec- 
tion with such sources of infection as damp and filthy cellars, 
stagnant pools reeking with the products of the decomposition 
of animal and vegetable substances, foul privies, wells con- 
taminated with excrementitious matter, etc., and, in cities,, 
with bad sewerage and defective plumbing and ventilation, 
and the combined results of poverty, filth and overcrowding 
of habitations, are too numerous and striking to be rationally 
regarded as mere coincidences. 

As out-door visiting physician to the Demilt Dispensary in 

1 Loc. cit. 



22 DIPHTHERIA; ITS NATURE AND TREATMENT. 

the twenty-first ward of this city through a number of years, 
I have had many opportunities of observing* the relation of 
occurrences of diphtheria to this class of causes, and was long- 
ago impressed with its tendency to occur and recur in certain 
tenement-houses where some of these conditions were most 
marked — such especially as foul and ill-drained cellars, neg- 
lected and sometimes overflowing cess-pools, and bad plumb- 
ing, with untrapped sinks and no air-shafts. The relation of 
cause to effect in these instances has been demonstrated by 
the fact that in some of these buildings, which had come to be 
looked upon by me and by my assistants as diphtheria nests, 
there has been no recurrence of the disease for quite a number 
of years since the evils referred to were removed through the 
efforts of the Board of Health. It is probable, moreover, that 
it is, in some degree, at least, a result of the removal of these 
foci of the disease that the mortality from diphtheria in this 
district, which was in 1875 in proportion to population among 
the greatest in the city, has for quite a. number of years been 
among the least. 

In estimating the validity of the argument which has been 
urged against this view, from the fact, already referred to, 
that in many epidemics diphtheria has been observed to prevail 
among all classes indifferently, or even in some instances es- 
pecially among the classes whose hygienic surroundings were 
the best, it may be remarked that insanitary conditions are 
only one among many causes of diphtheria, and are certainly 
not essential to its occurrence; that they constitute the most 
potent factors in its endemic prevalence, but that when it is 
epidemic other causes, more direct and potent and yet to be 
considered, are often the efficient ones; and again, it is a seri- 
ous and dangerous error to assume that insanitary conditions 
are found only in the abodes of the poor. Unfortunately the 
application of sanitary science to the construction of dwellings 
has not yet attained such perfection, nor is its assistance so 
generally and so intelligently invoked even in the abodes of the 



ETIOLOGY. 23 

wealthy, that any absolute line of demarcation can be drawn 
between them and the dwellings of the poor, either in city or 
country, in respect to their liability to or exemption from the 
causes of zymotic disease. In some instances the elaborate 
and luxurious appliances of modern plumbing- have seemed to 
multiply, rather than to obviate, the insidious dangers from 
noxious miasms. While, as I have already stated, I have seen 
many cases of diphtheria, evidently resulting from insanitary 
conditions in the abodes of the poor, I have also seen equally 
striking instances of this connection in the homes of the well- 
to-do and in the mansions of the rich. 

Insanitary conditions may favor the occurrence of diphthe- 
ria in two ways : by producing diseases which predispose to 
the reception of the special poison which causes diphtheria, 
and by the endemic perpetuation and reproduction of that 
poison, or possibly by its generation de novo. 

Diphtheria, or a disease which closely resembles it etiolog- 
ically and pathologically, occurs in various kinds of animals, 
poultry and birds, and seems to be intercommunicable between 
them and man. 

Facts confirming this statement have been published in 
great numbers by Mcati, 1 Friedberger, 2 Wood and Formad, 3 
Turner, 4 Delthil, 5 Paulinis 6 and many others. The following 
instance was published by Gerhardt : 7 

" In the village of Messelhausen, near Landa in Baden, a 
chicken-farm had been started into which 2,600 chickens had 
been brought from the country near Yerona, Italy. A few 
of these had diphtheria, and within the first six weeks 600 of 
them died of the disease, and, later on, 800 more. The follow- 



^'Compt. rend." 1879, torn. 88, No. 6. 

2 Zeitschr. f. Thiermedecin und vergl. Pathol., 1879, v. 161. 

3 National Board of Health Bulletin, 1882 ; Supplement No. 7. 

4 Report to the Local Government Board of London, 1887. 

5 Journ. de MeU, Feb. 19, 1888. 

6 Bull. M6d., Jan. 22, 1888. 

1 Verhandlung d. Cong, f . innere Medicin. Wiesbaden, 1883. 



24 diphtheria; its nature and treatment. 

nig- summer 1000 chickens were hatched from eggs laid by 
these hens, and all of these died of diphtheria within the first 
six weeks. Five cats succumbed to the same disease at this 
farm, and a parrot also took the disease, but was saved. In 
November, 1881, an Italian rooster, about to be touched up with 
carbolic acid, bit one of the attendants in the left hand and 
foot. The man was taken sick with high fever and both wounds 
were covered with diphtheritic membranes. The wounds 
healed very slowly, the disease lasting three weeks. Two-thirds 
of the farm hands became affected with diphtheria, and at the 
same time not a case occurred in the neighboring village." 

Paulinis relates that on an island in the Greek Archipelago 
on which diphtheria had been previously unknown, an epidemic 
among its population resulted from taking thither turkeys 
affected with the disease. The contagion seemed to be trans- 
mitted through the atmosphere. The affection in the turkeys 
resembled in all its features the human disease. One of them 
which recovered was affected with paralysis and was unable 
to walk. i 

Diphtheria occurs as the result of contagion and infection. 
This is abundantly demonstrated. Volumes might be filled 
with the recorded facts which illustrate it, such as the first 
introduction of the disease into a family or a school or a neigh- 
borhood by the arrival of a person suffering from it, and its 
subsequent dissemination by communication from one to an- 
other throughout the community, or its introduction into one 
country from another in the same manner, and its subsequent 
epidemic diffusion through that country along lines of travel 
and from one centre of infection to another. Such instances 
are far too numerous and precise to admit of explanation 
merely by endemic or epidemic influences. Nor is their force 
in the least weakened by the fact that many cases and epi- 
demics have occurred which could not be thus accounted for. 
Diphtheria is contagious, though all cases of diphtheria are 
not due to contagion. 



ETIOLOGY. 25 

Diphtheria is contagious in a less degree than scarlatina or 
measles or small-pox or whooping-cough ; it is less infectious 
than scarlatina or variola or typhoid fever; nevertheless in 
many instances it manifests both these qualities in an extreme 
degree. 

Diphtheria is communicated in a variety of ways. The 
first of these is by direct contact or the deposition of diphthe- 
ritic matter on the mucous membrane or upon wounds in the 
skin. 

Examples of this mode of transmission are furnished by 
numerous well-known instances in which physicians have con- 
tracted the disease by sucking out tracheotomy tubes, or by 
receiving the secretions of the patient in the mouth or nares; 
also by such instances as that related by M. See, 1 in which a 
woman- who wet-nursed a child affected with diphtheria, com- 
municated labial diphtheria to her own child, which she also 
nursed, and received the same affection from the latter by fre- 
quently kissing it. 

The demonstration afforded by the instances referred to is 
not at all weakened by the fact that many other physicians 
have sucked out tracheotomy tubes and have received diph- 
theritic secretions in their mouths and nares, or that other 
mothers have suckled and kissed infants affected with diph- 
theria, or that M. Peter 2 and others have painted their own 
fauces with solutions of false membrane without diphtheria 
resulting. The power of resistance of the healthy mucous 
membranes, especially in adults, to diphtheritic infection, is, 
undoubtedly, very great, and the infective power of diphthe- 
ritic material from different sources, as will be shown further 
on, varies very much. Under these circumstances a limited 
number of positive examples of the communication of diph- 
theria by direct contact, among many negative ones, is all 
the proof of its occurrence that could rationally be demanded. 

bulletin de la Soc. Med. des Hop., t. iv., p. 378. 
2 Trousseau, Op. cit. , vol. i. 



26 diphthekia; its nature and treatment. 

Diphtheria may be communicated by inoculation. Indeed 
this is implied in the fact of its communicability by direct 
contact, since in that mode of transmission penetration of the 
epithelium by the infecting- matter is evidently an essential 
condition. 

The communicability of diphtheria by inoculation is illus- 
trated in such instances as that related by Dr. Paterson, 1 of 
the disease being- communicated to a wound on a finger which 
was thrust down the throat of a child who was suffering from 
it. In other instances inoculation has been effected by the 
biting of the finger by the child. 

I witnessed not long since an instance of auto-inoculation 
by transplantation. A lady whom I saw in consultation with 
Dr. C. L. Lang of this city had labial diphtheria. She was 
also suffering from eczematous spots on her lower limbs which 
annoyed her by itching and burning. To allay this discomfort 
she placed upon one of them, which was particularly accessi- 
ble and troublesome, a bit of blotting-paper moistened with 
her saliva. In a day or two this patch became diphtheritic 
and continued so for some days, but none of the neighboring 
patches was similarly affected. 

That the communication of diphtheria by inoculation is at- 
tended with difficulty and uncertainty, is shown by the fact 
that Trousseau, Peter and Duchamp scarified their own fauces 
with scalpels charged with diphtheritic matter without result. 
Experiments in the inoculation of animals with diphtheritic 
matter have been attended with very varying results. These 
have been negative in many instances, as in the attempts of 
Bretonneau, Reynal, Harley and others. Trendelenberg, 2 in 
sixty-eight operations in which he introduced diphtheritic 
pseudo-membrane into the trachea of rabbits and pigeons, 
produced tracheal diphtheria in eleven, most of which died of 
croupal asphyxia. "With the membrane obtained from these 

1 Med. Times and Gazette, 1866. 

2 Arch, fur Klin. Chir., t. x., 1869. 



ETIOLOGY. 27 

victims he performed a second series of experiments with sim- 
ilar results. Oertel, 1 in twelve similar experiments upon rab- 
bits, produced tracheal diphtheria in eight, five of which died 
by asphyxia, and three from toxaemia, the autopsies showing- 
capillary hemorrhages in various organs, and marked renal 
congestion. With the membrane obtained from these rabbits 
he produced similar results in a second series of operations, 
and repeated them in a third. Drs. H. C. Wood and Henry 
F. Formad 2 performed intra-tracheal inoculation upon rabbits 
with like results in a small proportion of instances. 

Hueter and Tommasi and Oertel introduced diphtheritic 
matter into the muscles of rabbits. The result 3 was a diph- 
theritic layer on the edges of the wounds, hemorrhagic inflam- 
mation of the muscles and a general disease which proved fatal 
after one or two days. Nassiloff and Eberth, 4 by inoculating 
the cornea, produced diphtheritic keratitis which was accom- 
panied with a general affection which proved faW on the fourth 
or fifth day. The evidence that the affection induced in these 
instances was true diphtheria has been regarded as inconclusive 
by many. Drs. Curtis and Satterthwaite 5 repeated these opera- 
tions. In those made upon the cornea by them the result was 
negative. Of thirty-eight rabbits inoculated by them with 
diphtheritic matter in the muscles or by subcutaneous injection 
twenty-one died after periods varying from thirty hours to 
thirty-eight days. In these cases the authors "failed to see 
anything specifically resembling diphtheria as it occurs in the 
human subject. The whole story seemed to be one of local 
irritant poisoning which always tended toward the production 
of an abscess at the site of the inoculation, with greater or less 
concomitant hyperemia, ecchymoses and serous infiltration of 

] Deutsch. Arch, fur Klin. Med., 1871. 

National Board of Health Bulletin, 1882; Supplement No. 17. 
3 Ziemssen's Cyclopaedia, vol. i. 
4 Correspondenzblatt, 1872. 

5 "Report of Investigations into the Pathogeny of Diphtheria," by 
Edward M. Curtis and Thomas E. Satterthwaite. New York, 1877. 



28 diphtheria; its nature and treatment. 

neighboring- tissues according to the degree of virulence of the 
inoculated poison." 

Drs. Wood and Formad, 1 on the other hand, in a small pro- 
portion of their subcutaneous and intra -muscular inoculations 
of rabbits with diphtheritic matter, produced a rapidly fatal 
local and general affection, which strikingly resembled diph- 
theria, and which they regarded as probably essentially iden- 
tical with it. 

In the recorded experiments for the communication of 
diphtheria to the lower animals by inoculation it is to be ob- 
served that the operation is attended with great uncertainty, 
succeeding in only a small proportion of all cases; that it has 
usually failed when attempted in the mucous membrane of 
the mouth and fauces, but has much more often succeeded in 
the trachea. 

Diphtheria may be communicated from one person to another 
through the circumambient air. This is undoubtedly its most 
usual mode of communication, as has been illustrated in the 
numerous instances in which the disease has been contracted 
by persons entering rooms or houses in which were patients 
suffering from it, or has been brought by those affected with it 
to persons or families previously exempt from it. The distance 
to which the disease can be thus conveyed by the atmosphere 
is ordinarily very small, though in some epidemics it has 
seemed to be wafted by the winds to considerable distances. 

The contagion from patients affected with diphtheria 
seems to accumulate in their rooms, to adhere to walls and 
furniture, and often to linger for a considerable time after 
their recovery, as has been shown by numerous instances in 
which persons have taken diphtheria in rooms in which cases 
of the disease had occurred weeks or months before, It seems 
also to linger about the persons or in the clothing of those who 
have had the disease for some time after their recover}^ Some 
recorded instances also seem to show that the contagion may 

1 Loc. cit. 



ETIOLOGY. 29 

be carried in the clothing- of those who have been exposed to 
the infection of the disease, but not affected with it themselves, 
and communicated by them to others. 

The following- is one of many such instances : Dr. J. H. Sal- 
ter * states that in a farm-house situated in a high and dry 
locality, and several hundred yards from any other house, a 
boy of eleven years was attacked with diphtheria on October 
24th, and within the next six days his father, another child and 
three servants came down with the disease. There was no 
epidemic in the neighborhood. It was learned on investigation 
that on October 19th a woman from another village, two miles 
away, had brought back some needlework from her cottage, 
which contained at the time two sick children. One child had 
died rather suddenly from what was called " bronchitis." The 
other was seen by the health-officer with well-marked diphthe- 
ria. There were no other cases for miles around. The infec- 
tion seems to have been carried by the woman in her clothing 
or in the needlework. She did not herself have the disease. 

The contagion of diphtheria may probably be conveyed by 
articles of food and drink, such as milk, etc. Observations in 
some epidemics of diphtheria have seemed to establish some 
connection between its occurrence and the milk-supply. Some 
have thought it probable that the disease known as garget in 
cattle might be a source of diphtheritic infection. The agency 
of such substances as carriers of diphtheria is, however, not 
fully demonstrated and is probably not among the very fre- 
quent causes of the disease. 

That diphtheria occurs epidemically is one of the most 
notable facts in connection with its etiology. It is evident 
that at such times the contagion of the disease is more potent 
than at others, as it is propagated and disseminated by the 
various modes of communication which have just ])een enumer- 
ated independently of local conditions, and with an intensity 
and certainty of action which is rarely seen in connection with 
1 British Medical Journal, Dec 1, 1883. 



30 diphthekia; its nature and treatment. 

the endemic and sporadic forms of the disease. This differ- 
ence in respect to virulence of contagion between epidemic and 
sporadic or endemic cases is strikingly illustrated in the results 
of the experiments of Drs. Wood and Formad already referred 
to. Of thirty-two rabbits inoculated with diphtheritic matter 
from endemic cases only six died, and none of those from 
diphtheria; of fifteen, inoculated with matter from the Lu- 
dington epidemic, eleven died, and four of these with abundant 
diphtheritic exudation at the site of inoculation. It is not im- 
probable that many of the discrepancies in the results of ex- 
posures to contagion and of inoculation-experiments may be 
thus accounted for. 

It is next in order to inquire what is the nature of the 
contagium of diphtheria. It seems probable that a materies 
morbi which may be communicated by direct contact and 
by inoculation, which may be suspended in and conveyed by 
the atmosphere and by gases and liquids, which may be shut 
up in apartments and adheres for a considerable time to walls 
and furniture and persons and clothing, and which is repro- 
duced and disseminated in the course of the disease is in 
the form of solid particles, rather than of a liquid or a gas, or 
at least is conveyed by such particles. This may also be in- 
ferred from the manner in which the disease usually commences 
upon the mucous membrane of the throat, the nares or the 
mouth, namely, in points or in small limited non-symmetrical 
areas rather than with the general diffusion which would 
characterize the action of an inhaled poisonous gas or vapor 
either acting from without or from within through the circu- 
lation. This probability is also sustained by the results of ex- 
periments. Curtis and Satterthwaite 1 state that "Thorough 
filtration of a proven virulent aqueous infusion of diphtheritic 
membrane removes the infectious property of the same." 
And the same results have been reached by many others. 

Is this contagium a chemical poison or is it a micro-organ- 

1 Loc. cit. 



ETIOLOGY. 31 

ism, or, what is practically equivalent to the latter, is it a 
chemical poison which is the product of such an organism? 

Such convincing- arguments have of late years been brought 
forward to prove that the phenomena of contagious and in- 
fectious diseases can be fully accounted for by the agency of 
micro-organisms and in no other way — arguments which are 
too familiar to need present repetition — that the microbe of 
diphtheria has long been eagerly sought for by many and its 
ultimate discovery confidently anticipated by the majority of 
the profession. No such discovery yet supposed to have been 
made has met with unchallenged and universal acceptance; 
yet in the course of the search various facts have been elicited 
of such interest that a brief review of them is essential to our 
present inquiry. 

Professor Laycock, 1 in 1858, was the first to find a supposed 
parasitic cause for diphtheria in the oidium albicans. Other 
microscopists subsequently observed other organisms in con- 
nection with the disease, as the zygodesmus fuse us of Letze- 
rich 2 and the leptothrix buccalis of Jaffe, 3 which were in turn 
found to be common to other diseases, or even present in con- 
ditions of health. 

In 1868 the micrococcus, — an organism previously observed 
by Buhl — was brought forward by Oertel 4 as the specific mi- 
crobe of diphtheria. The micrococcus is a minute, point-like, 
dark-contoured, round or oval immovable body, occurring 
singly, in chains, or in zooglea (masses). 

According to the earlier observations of Oertel the micro- 
coccus was always accompanied in diphtheria by a small form 
of the bacterium termo (a rod-bacterium). He stated that 
these organisms were always to be seen in rapidly increasing 
numbers upon the mucous membrane at points where diph- 
theritic false membrane was about to develop, but were 

1 Med. Times and Gazette, vol. xxxviii. , p. 548. 

2 Virchow's Arch. B. xlv. et seq. Schmidt's Jahrbuch, 1862. 

4 Studien iiber Diph. Aertzl. Int., 1868. No. 34. 



32 diphtheria; its nature and treatment. 

never present in other forms of inflammation, that they pene- 
trated into the tissues, caused the dissolution of the young* cells, 
filled and obstructed the blood and lymph-vessels, appeared 
heaped up in the miniferous tubules and the Malpigrhan cor- 
puscles of the kidneys, and, in short, were found in the most 
diverse situations and were inseparable from the diphtheritic 
process. The observations of Oertel were more or less fully 
corroborated by those of Von Recklinghausen, Nassiloff, Wald- 
eyer, Klebs, Eberth, Heiberg, Trendelenberg and Letzerich. 

These views were controverted by Beale, 1 Senator, 2 Bill- 
roth, 3 Curtis and Satterthwaite 4 and others, who denied the 



<e% 






Fig. 1. — Diphtheritic False Membrane Containing Micrococci, z, Zooglea formed by small 
micrococci; z', Zooglea formed by larger micrococci; m, Isolated microbes. X 500. (Cornil 
and Babes.) 

specific character and the pathogenic function of these para- 
sites in diphtheria. 

The observations of Wood and Formad, already referred 
to, were in some respects in accordance with those of Oertel, 
though their conclusions were somewhat different. In freshly 
removed false membrane micrococci only were found by them. 
Other forms of bacteria were found in membrane which had 
been removed some hours previously or which was removed 
post-mortem. 

In examinations of the blood of human being's during life, 

micrococci were found in one of seven cases of sporadic diph- 

1 Disease Germs. London, 1872. 

2 Archiv. fUr pathol. Anat. und Physiol., t. lvi., 1872. 
8 Untersuclmngen tiber Vegetations-formen der Cocco-bacteria Sep- 
tica, etc. Berlin, 1874. 4 Op. cit. 



ETIOLOGY. 33 

theria, and in seven of fourteen of epidemic diphtheria. The 
seven of the latter class in which they were not found were 
mild or in the stage of convalescence. Micrococci were, how- 
ever, also found in the blood during" life of one case of unknown 
disease in hospital which resulted fatally, and in two of scar- 
latina anginosa with exudation. 

" Both septic animal matter and non-organic irritants placed 
in the trachea cause pseudo-membranous tracheitis, which we 
have failed to distinguish from diphtheritic tracheitis, the 
membrane in both cases containing micrococci. The occur- 
rence of a false membrane in the trachea is the result not of 
the specific character but of the intensity of the inflammation. 

" The micrococci of diphtheria do not differ, so far as ob- 
served, from the micrococci of furred tongue, etc., except in 
their tendency to grow in culture fluids. 

"The micrococci of furred tongue or ordinary sore throat 
have a less tendency to grow under culture than have the 
micrococci of endemic non-malignant diphtheria; and the lat- 
ter much less than the micrococci of malignant diphtheria. 

" The rapidity of the growth of the micrococci is in direct 
proportion to the malignancy of the case yielding them and 
its contagiousness. 

" On exposure to the air diphtheritic membrane of the most 
virulent type loses its contagious power, and the micrococci, 
pari passu, lose their power of growing in culture-fluids. 

" Under successive generations of artificial culture the diph- 
theria micrococci lose their growth activity and also their 
power of infecting the rabbit. 

" It has not been experimentally directly proven, but is a 
necessary inference from the two facts just stated, that under 
certain favoring circumstances the sluggish micrococcus puts 
on growth activity and in all probability poisonous properties. 

"Every grade of case may be found in man, from a simple 
sore throat through simple membranous pharyngitis and tra- 
cheitis up to malignant diphtheria. 



34 diphtheria; its nature and treatment. 

"Any inflammation of the trachea of sufficient intensity 
may cause the formation of a pseudo-membrane. 

"A case may beg-in as one of sthenic ' pseudo-membranous 
croup/ and end as one of adynamic diphtheria with blood- 
poisoning*, and in cases of this character not infrequently no 
exposure to contagion is discoverable, and there is clinically 
every reason to believe that the ' blood-poison ' has been devel- 
oped within the body of the patient. The theory of the disease 
which we would deduce from these facts is that the micro- 
coccus which directly or indirectly causes the diphtheria is 
not a specific organism different from that common to healthy 
and inflamed throats, but is an active state of that organism ; 
that certain circumstances outside of the human body are 
capable of throwing this micrococcus into this condition of 
active growth and engendering an epidemic of diphtheria. 
When diphtheria is thus epidemic the micrococci light upon a 
throat, and, if the throat have little resisting power, as in the 
child, inflame it, or increase a catarrh already existing into a 
violent inflammation, and also rapidly enter the blood and 
cause systemic poisoning. On the other hand, a catarrh in a 
weakly subject may in the beginning be simply an inflamma- 
tion from cold, but the ordinary micrococci in the mouth and 
throat, favored by the special conditions, may gradually change 
from the dormant to the active state, and by and by act upon 
the throat and at last force their way into the system, and a 
self -generated diphtheria be formed out of a cold." 

This theory is in essential accordance with that stated by 
Rindfleisch : * " The apparently sudden outbreak of devastating 
plagues, like cholera, syphilis or diphtheria, is best explained 
by supposing that a fungus growing as an epiphyte has sud- 
denly gained the power of growing as an endophyte, thus cre- 
ating an apparently new infection." 

Other forms of bacteria have been found by various inves- 
tigators in apparent pathogenic relation to diphtheria. Among 
" Elements of Pathology." 



ETIOLOGY. m 35 

these is the " tilletia diphtheritica," a later discovery of Letze- 
rich 1 than the zygodesmus fuscus. Another is the " microspo- 
ron diphtheriticum," described by Klebs 2 as consisting- of small 
micrococci compacted in round balls, surrounded with a thin 
layer of gelatinous matter. These subsequently develop into 
minute motile bacilli, and finally into tufts of mycelium. 

Klebs stated at the German Medical Congress in 1883, that 
he had found this form of bacteria in connection with a grave 
form of diphtheria at Prague, which was characterized by 
prominent nervous symptoms and hemorrhagic formations in 
the brain and spinal cord on post-mortem examination. As 
he had found these organisms transmittible to the cornea, he 
had regarded them as the specific fungi of diphtheria. 

Later, however, at Zurich he had seen cases of diphtheria 
of an entirely different character. The false membrane of the 
throat had a great tendency to extend into the larynx and 
trachea, followed by interstitial inflammatory processes in in- 
ternal organs. The micro-organisms in these cases were of 
an entirely different character from those found in former 
ones. Instead of being globular they were exclusively bacil- 
lar formations. Hence he had distinguished two forms of diph- 
theria — the diphtheria microsporon and diphtheria bacillaris. 

M. Talamon, in January, 1881, gave to the Anatomical So- 
ciety of Paris a minute description of still a different bacterium 
which he had discovered in connection with diphtheria, and 
which appears under the form of mycelia and characteristic 
spores. Talamon had produced diphtheria (or an affection 
having all its essential features) in rabbits, guinea-pigs, cocks 
and pigeons by inoculating them with this fungus, and in frogs 
by simply feeding them with it. 

Emmerich 3 arrived at yet different results. The organism 
which he found to occur distinctively in the diphtheritic lesions 
of both man and pigeons was neither a coccus nor a bacillus, 

x Loc. cit. 2 Archiv. f. exper. Pathol, und Therap., vol. iv., p. 191. 
3 Deutsch. Med. Wochenschr. 1884, No. 38. 



36 diphtheria; its nature and treatment. 

but a short thick bacterium. Inoculated from cultures into 
pigeons, rabbits and mice, these bacteria produced character- 
istic local diphtheritic lesions and a rapidly fatal general dis- 
ease. 

The most important bacteriological investigations which 
have yet been made in connection with diphtheria are those 
of Dr. Friedrich Loeffler. 1 Attributing the unsatisfactory re- 
sults of previous attempts to discover the specific microbe of 
diphtheria to the inherent difficulties attending them, from 
the great number of different fungi present in the disease, and 
also to the insufficient methods which had been employed, 
since only impure material had been used in cultures and in- 
oculations without separation of the different organisms, he 
was therefore induced to apply the more accurate methods of 
Koch to the investigation. He first made histological exami- 
nations, with an improved method of staining, of the affected 
mucous membranes and internal organs of twenty-seven pa- 
tients who had died of diphtheria, including five cases of scar- 
latinal diphtheria. In these examinations he found two forms 
of bacteria especially numerous, viz., micrococcci in chains 
(streptococci) and a form of bacillus. The micrococci were 
not present in all cases. They were probably the same which 
had previously been so generally observed in diphtheria. 

Thej" were found not only on and in the affected mucous 
membranes in some cases, but also in the lymphatics, whence 
they penetrated to every part of the body, causing necrosis of 
the tissues. Micrococci morphologically identical with these 
are, however, also found in various other diseases which are 
accompanied with lesions of the mucous membranes, such as 
variola, typhoid and puerperal fever, etc., in which diseases 
their presence is regarded as entirely accidental. 

1 Mittheilungen aus dem k. Gesundheitsante, Berlin, vol. ii., 1884. 
Abstracted by Dr. J. W. Hime in " Microparasites in Disease," New 
Sydenham Soc, 1886, and by Dr. M. Putnam- Jacobi, in the Quarterly 
Bulletin of the Clinical Society of the New York Post-Graduate Medi- 
cal School and Hospital, August, 1885. 



ETIOLOGY. 37 

The bacilli were probably the same which had been first 
described by Klebs. They are non-motile, either straight or 
curved, about the length of the bacillus of tubercle, but twice 
as thick. They were found exclusively in those typical cases 
of diphtheria which were characterized by thick false mem- 

%% »:* 







Fig. 2.— The Streptococci found by Loeffler in Diphtheria. X 1250. 

brane in the fauces, larynx and trachea. In this false mem- 
brane they were very numerous, and they were found in deeper 
layers of it than were the micrococci and other accidental bac- 
teria, which only occurred superficially. The bacilli were not 
found in the internal organs, the blood-vessels or the lymphat- 
ics, and if they are really the cause of diphtheria, they are so 
not by themselves penetrating* the system, but by producing 
a poison which first acts locally, producing tissue necrosis, 
vascular paralysis and dilatation, and exudation of fibrogenous 




Fig. 3.— Bacilli on the Surface of False Membrane of Vulvar Diphtheria, and in a Crevice 
between the Filaments of Fibrin which compose it. X 400. (Cornil and Babes.) 

lymph, and then entering the circulation causes the constitu- 
tional disease. 

The bacilli were not found in all typical cases. It was, 
however, possible that they might have been present, but have 
died and been eliminated before the patient's death. The re- 



38 diphtheria; its nature and treatment. 

suits of the histological investigations were upon the whole in- 
conclusive. 

The bacteria described were next cultivated by the usual 
processes for isolation from the fourth to the twenty-fifth gen- 
eration. 

The products of these cultures were then inoculated upon 
mice, guinea-pigs, rabbits, monkeys and birds. 

Inoculations with the streptococci in no instance produced 
a disease even resembling diphtheria. For this and other rea- 
sons Loeffler concluded that they cannot be regarded as the 
specific cause of the disease, though it is probable that they 
may under some circumstances produce a disease resembling 
diphtheria. 

Cultivations of the bacilli introduced beneath the skin of 
guinea-pigs and small birds killed them, producing* whitish or 
hemorrhagic exudations at the point of inoculation, and exten- 
sive subcutaneous oedema, the internal organs being unaffected. 
Inoculated in the trachea of rabbits, fowls and pigeons, or the 
vagina of guinea-pigs, the poison produced a false membrane. 
There was also the characteristic alteration of the vascular 
walls which shows itself by bloody oedema, hemorrhage into 
the tissue of the lymphatic glands and effusion into the pleural 
cavity. The bacilli have, therefore, the same effect as the 
diphtheritic virus. 

Their specific character is seemingly opposed by the follow- 
ing facts: They were absent in a number of undoubted cases 
of diphtheria; they were not present in typical quantity and 
arrangement in the artificially produced pseudo-membranes; 
they had no effect when applied to the uninjured surface of 
mucous membranes in some animals otherwise susceptible to 
their action; animals which survived showed no paralysis; 
identical bacilli were found in the saliva of healthy children. 
Proof that these bacilli are the cause of diphtheria is therefore 
incomplete, though the possibility of their being so is not ex- 
cluded. 



ETIOLOGY. 6V 

The investigations of Babes 1 in twenty-four cases of diph- 
theria confirmed in a general sense the observations of Loeffler. 
In every case there were streptococci and the bacilli of Loeffler. 
In the cultures made from false membranes the streptococci 
were more numerous, but the bacilli invaded and overwhelmed 
them, remaining" finally the sole masters of the field. 

The bacilli were found in the depth of the tonsils in dense 
masses, and sometimes. in the retro-pharyngeal ganglia. In 
the bronchial ganglia streptococci only were found. These 
bacteria were in some cases accompanied by other pathogenic 
microbes — the staphylococcus aureus and an encapsulated mi- 
crobe resembling that of pneumonia. 

In cutaneous diphtheria bacilli were observed not only in 
the false membrane, but also on the free surface of the papillae, 
and in smaller numbers in the connective tissue and the di- 
lated vessels of the inflamed papillae, and more rarely in the 
tissue of the derma. 

In reference to the organisms of human diphtheria, Cornil 
and Babes say : " We think that the bacilli of Klebs and Loeff- 
ler ma,y be regarded as the most important agents in the 
production of the. false membrane of true diphtheria, but it 
must be admitted that physiological researches in the case of 
that disease have not yet given their final response." 

Dr. A. D'Espine, 2 President of the Medical Society of Ge- 
neva, has found the bacillus of Loeffler in every one of fourteen 
cases of diphtheria and croup, and absent in all of twenty-four 
cases of simple anginas studied by him. In a case of croup a 
pure culture was obtained which preserved its pathogenic 
powers through twenty-five generations, as was proved by 
inoculation experiments. Dr. D'Espine believes that this is 
the pathogenic organism of diphtheria and croup, that it pro- 

1 " Les Bacteries et leur role dans l'anatomie et l'histologie patholog- 
iques des maladies infectieuses," par A. V. Cornil et V. Babes. Paris, 
1886, p. 458. 

2 Revue Medicale de la Suisse Romande, No. 1, January, 1888, p. 49. 



40 DIPHTHERIA; ITS NATURE AND TREATMENT. 

duces a leucomaine which, when absorbed, gives rise to the 
systemic poisoning-, and that its presence or absence may be a 
reliable diagnostic criterion. 

On the other hand, Yon Hoffmann- Well enhoff l has found 
the bacillus of diphtheria of Loeffler in seven cases of pharyn- 
geal diphtheria, in three cases of measles, in six out of nineteen 
cases of phalangitis complicating scarlatina, and in four out 
of eleven cases which had no perceptible abnormalities. Tests 
in regard to the virulence of cultures of these bacteria showed 
that a number of those which were obtained from diphtheritic 
as well as non-diphtheritic cases caused in animals the symp- 
toms described by Loeffler, while other cultures morpholog- 
ically identical with them were perfectly harmless in the ex- 
periments made. 

Oertel in his late important work, Die Pathogenese der 
Epidemischen Diphtherie, Leipzig, 1887, page 141, et seq., re- 
ferring to his former statement (previously quoted) that he 
had always found the micrococcus accompanied in diphtheria 
by a rod-bacterium, states that this rod-bacterium and the 
bacillus of Klebs and Loeffler very nearly coincide in their 
measurements, and also in the knobbed appearance of one or 
both of their extremities, and are in all probability iden- 
tical. 

A new series of observations by Oertel on the micro-organ- 
isms present in diphtheritic membrane, may be roughly stated 
as in general correspondence with those of Loeffler. 

In a recent series of post-mortem examinations Oertel has 
failed to find micrococci present in the kidneys in any case. 
This difference from his earlier observations he explains by 
the fact that the more recent cases have been of a less markedly 
septic type than the former ones. 

While these facts obviously suggest the hypothesis that 
diphtheria is the result of a mixed infection by specific bacilli 

Archives of Paediatrics, January, 1889, from Jahrb. f. Kinderh., 
xxviii., 2. 



ETIOLOGY. 



41 



and septic micrococci, Oer- 
tel does not consider that 
this conclusion is as yet ful- 
ly established. 

Oertel also states that 
no bacteria can be found in 
diphtheria in the interior of 
the diseased cells in any sit- 
uation, nor in the necrobio- 
tic foci at any stage, nor in 
the parenchyma of the in- 
ternal org-ans, nor on their 
surface in such situations as 
make it probable that they 
are the immediate cause of 
the disease. Hence it is to 
be inferred that their mor- 
bific action must be due to 
the chemical poisons or 
ptomaines which they cause 
to be produced in the sub- 
stances in which they live. 
He believes that this poison 
or virus first passes into 
and through the epithelium, 
induces alterations in the 
tissue -fluids, excites irrita- 
tion and inflammation, and 
thus inaugurates the train 
of morbid and necrobiotic 
processes which is elsewhere 
described. In the course of 
these processes the poison 
is reproduced both by the 
multiplication of bacteria 







FN. 



wm- 



>>■■$■■::<. 



m 



om 



® 



20 









'$&. 



"? 



Om!, 



FN. 






; ox 









BZ. 









Fig. 4.— The Extension of Bacteria into the Fi- 
brinous Exudation. (Oertel.) B.V., bacterial vege- 
tations; F.N., fibrinous network; L, leucocytes, 
their degeneration, division and disintegration be- 
ing indicated to a slight extent only; B.Z , chains 
of rod-shaped bacteria with knobbed extremities. 



42 diphtheeia; its nature and treatment. 

and by fermentation-changes in the decomposing- substances, 
and becomes more and more widely diffused. 

Diphtheria, as a general rule which is subject to relatively 
very few exceptions, occurs only on those surfaces of the body 
which are exposed to the access of the air. This suggests that 
among the conditions which are usually necessary to produce 
it is the presence of free oxygen. Bacteria, according as the 
presence of free oxygen is necessary or hurtful to them, are 
classed as aerobious or anaerobious. From the circumstance 
just referred to it has been inferred that the bacterium of diph- 
theria is aerobious. Dr. B. K. Rachford, 1 in taking this view, 
suggests that the occasional, but rare, occurrence of diphthe- 
ria in the stomach and intestines, where free oxygen is not 
present, may take place under exceptional conditions in which 
oxygen is supplied in some unstable combination in which it 
may be utilized for the sustenance of the bacteria of the dis- 
ease, and that that condition may be one of congestion and 
erosion of the gastric or intestinal mucous membrane, in which 
the oxygen is thus supplied by the oxyhemoglobin of the blood. 
In proof that this explanation is not far-fetched he cites the 
fact that strictly aerobic germs, such as anthrax, live and mul- 
tiply in the body, deriving their oxygen from this source. 

The search for the specific bacterium of diphtheria has been 
stimulated by the general belief that diphtheria is a specific 
disease like scarlatina or small-pox, which, according to prev- 
alent theories, must have a single parasitical cause. The hy- 
pothesis that it may, on the other hand, include several gen- 
erically related and resembling septic processes with specific 
differences and dependent on the action not of one but of vari- 
ous bacteria, has been entertained by some and is perhaps, at 
the present imperfect stage of our knowledge, worthy of a 
moment's consideration. It is not inconceivable that croupous 
and diphtheritic inflammation maybe capable of being excited 
by the action of more than one kind of bacterium, as it is 
1 Medical News, Feb. 2, 1889. 






ETIOLOGY. 43 

known that morbid processes closely resembling- them may be 
by various chemical and mechanical agencies. 

This supposition is favored by the remarkable differences 
which have been observed in the form and course of these proc- 
esses. The differences in the clinical features and the patho- 
logical lesions of constitutional diphtheria are even more strik- 
ing-, and although in the majority of cases they conform to 
certain general types, yet the deviations from those types are 
in some instances so wide that they would seem to be more 
readily explicable by the hypothesis of different infections, or 
" mixed " infections, than by any other. That mixed infections 
or intoxications should occur through a favorable habitat 
being afforded to some pathogenic organisms by tissue changes 
previously caused by others, or the conversion thereby of pre- 
viously innocuous to pathogenic ones is in accordance with 
many known facts. 

It can hardly be doubted that the important questions 
thus suggested respecting the etiology of the various forms 
and complications of diphtheria, will ere long be finally an- 
swered by the multiplication of precise investigations. 

The following conclusions from facts aud considerations 
which have now been presented may be regarded as probable : 

1. Diphtheria is caused by a parasite which has the follow- 
ing characteristics : Its growth and multiplication outside of 
the body are favored by dampness and insanitary conditions, 
and it is reproduced in the disease; its presence on mucous 
membranes is sometimes innocuous; its vital activity is greatly 
increased under the conditions which prevail during an epi 
demic; its pathogenic action is greatly favored by pre-existing* 
morbid conditions of the body, and especially those involving 
lesions of the epithelium ; it is transmitted from one person to 
another by the various processes which are most usually in- 
cluded under the terms contagion and infection. 

2. This parasite causes diphtheria by being implanted on a 
mucous membrane or a wounded surface of the body or in its 



■±4 diphtheria; its nature and treatment. 

more superficial tissues, and there producing a chemical poi- 
son, or ptomaine. 

3. This poison, or ptomaine, by its direct action on the tis- 
sues and vessels causes the local diphtheritic process, in the 
course of which it is reproduced and more and more widely 
diffused, and by its absorption from this source into the gen- 
eral circulation causes the constitutional disease. 

4. This morbid process is often accompanied or followed by 
the invasion of the body by other pathogenic bacteria, to which 
various complications are due. 

5. ISTo bacterium thus far discovered in connection with 
diphtheria can furnish by its presence or its absence a reliable 
criterion for xliagnosis. 

Incubation.— The period of incubation in diphtheria — that 
is, the time from the actual reception of the contagium into 
the system to the appearance of the disease — is for obvious 
reasons in the great majority of cases impossible to ascertain. 
The only cases in which it can be accurately estimated are 
those in which the disease is known to result from a single ex- 
posure of short duration, and even in these cases there is an ele- 
ment of uncertainty, since there is reason to believe that the 
germ of the disease may be carried about the person innocu- 
ously — perhaps even on the buccal mucous membrane — for 
some time before it begins to exert a morbific influence. 

There are, however, abundant data for estimating the min- 
imum period of incubation in instances in which the disease has 
been brought to the members of a family or a school, or the 
inmates of a hospital, by persons affected with it. My own 
observation in many such instances corroborates that of most 
authors that the minimum period of incubation is usually about 
two days. Dr. Morell Mackenzie 1 relates an instance in which 
a child had the disease with abundance of false membrane the 
next morning subsequent to the afternoon of her first exposure, 
and another, equally definite, in which the interval between ex- 

1 Op. cit, p. 29. 



ETIOLOGY. 45 

posure and the development of the disease was fifteen days. 
A child in a family which had a few weeks before removed from 
a village in Pennsylvania where there had been no diphtheria 
to a neighborhood in this city where diphtheria was endemic, 
took the disease. During- her illness her father, who had re- 
mained behind, joined his family and at once devoted himself 
to the care of the child. The second morning (less than two 
days) after his arrival he came to me complaining of sore 
throat, and proved to be suffering from diphtheria. The usual 
period of incubation in diphtheria, in the sense in which the term 
is defined above, is probably from two to five or six days, 
though the interval between exposure and the resultant disease 
may be several weeks. 

In 1876 I saw, with Dr. J. E. Janvrin, of this city, a case of 
diphtheria at Dobbs' Ferry, of which the history was as follows : 
Mrs. H., with her son, aged seven, and his nurse, went on Sep- 
tember 1st to a hotel at Long Branch. On September 10th 
Mrs. H. was there attacked with diphtheria. There had pre- 
viously been other cases in the hotel. The child and nurse 
were at once sent to their home at Dobbs' Ferry, and Mrs. 
H. came to a hotel in this city, where she was attended by 
Dr. Janvrin from September 11th to 19th through a severe 
attack of pharyngeal diphtheria. She returned to her 
home on October 1st. On October 24th her son was 
attacked with a most malignant form of the disease, which 
terminated fatally. The probabilities in this case were either 
that the child had carried about himself the germs of the dis- 
ease for forty-four da3^s or that he had received them from his 
mother within the twenty-three days before his attack and at 
least twelve days after her recovery. There had been no pre- 
vious cases of the disease at that time at Dobbs' Ferry. 

[Some recent important contributions to the etiology of 
diphtheria are appended at page 259.] 



CHAPTER III. 

PATHOLOGY. 

Diphtheritic false membrane may be generally described 
as a somewhat tough, firm, compact, elastic substance. Its 
color is a yellowish or grayish white. In thickness it varies 
from that of a mere pellicle to two or three millimetres, and in 
extent from a minute patch to a coating- of the whole surface 
of the mouth and throat or a lining of the air-passages. In 
texture it is usually irregularly fibrillated, but is sometimes 
amorphous or granular or lamellated, and these conditions are 
often intermingled. It is tasteless and odorless, is insoluble 
in water, is dissolved by caustic alkalies, swells up and be- 
comes transparent under the addition of acetic acid, and in its 
physical and chemical properties closely resembles fibrin. 

Under the microscope false membrane is seen to consist of 
a network of fibrinous threads of varying thickness and close- 
ness, in the meshes or interstices of which are cells, namely 
leucocytes, red globules or epithelial cells, which have usually 
undergone a peculiar necrotic transformation. The relative 
proportions of these elements vary greatly in different cases. 

Diphtheritic false-membrane was regarded by the older 
writers as a gangrenous eschar, by Samuel Bard as altered 
and inspissated mucus, by Bretonneau and his successors as a 
coagulated fibrinous exudation analogous to that which occurs 
on the surface of serous membranes. It will be seen that there 
was an element of truth in all of these views. 

According to E. Wagner * false membrane is the result of 
a peculiar necrobiotic metamorphosis in the epithelial cells, 
^rchiv. f. Heilkunde, 1866, Bd. vii., p. 481. 



PATHOLOGY. 47 

which become enlarged, porous and irregular in shape, sending 
out peripheral projections which unite with those of adjoining 
cells, forming a homogeneous network in which nuclei can no 
longer be detected, and an accompanying infiltration of the 
corion, and, in some cases, the subjacent tissues, with new cells 
and nuclei and sometimes extravasated blood. 

Buhl 1 observed also an infiltration of the tissue of the mu- 
cosa, even in situations where it was not covered by false 
membrane, with cellular or nucleolar bodies. This infiltration 
he found widely diffused through various organs and regarded 
as characteristic of diphtheria. 

Boldyrew 2 and Steudener 3 opposed the views of Wagner 
as not confirmed by their observation, and assigned a leading 
place in the formation of diphtheritic membrane to vascular 
exudation.. 

Both of the processes just referred to, namely, fibrinous 
exudation and the necrotic metamorphosis of cells and tissues, 
are included in more recent views of the formation of diphthe- 
ritic membrane. 

The precise circumstances which in all cases favor or pre- 
vent the coagulation of inflammatory exudations upon the 
surface of mucous membranes are not fully known. Weigert 4 
has shown that in order that it may take place the epithelium 
must be wholly or partially destroyed. 

The coagulation of fibrin is not a mere solidification of a 
substance which previously existed as such in solution in the 
effused fluids, but is a new formation from the fibrin-generators 
which they contain. According to Alexander Schmidt the 
plasma of the blood contains fibrinogen, and the white corpus^ 
cles and probably other ceils furnish fibrinoplastin and a fer- 
ment. When the white corpuscles die and are dissolved in the 
plasma the result is the production of fibrin. 

^eitschr. f. Biol., Bd. iii., S. 349, 1867. 
2 Archiv. f. Anat. u. Phys., 1872, p. 75. 
3 Virch. Archiv., 1872, liv., p. 500. 
4 Virch. Archiv., Bd. lxxix. 



48 diphthekia; its nature and treatment. 

The peculiar metamorphosis of cells and tissues which 
occurs in the formation of pseudo-membrane was named by 
Cohnheim coagulative necrosis, and its nature was made known 
to us chiefly by Weigert. It is a coagulation which occurs not 
only in effused vital fluids, but in the substance of cells and 
tissues. That it shall take place it is necessary that the cells 
or tissue elements shall die or be in the process of necrotic de- 
generation, and that then effused lymph shall flow through 
them. Fibrin is formed within the tissue by the union of its 
two components just referred to. The death of the cells or tis- 
sues may be the result of injury from physical or chemical or 
thermal agencies or from arrested nutrition; the effusion of 
lymph is due to the vascular changes which accompany inflam- 
mation. 

Rindfleisch 1 says: 

"Coagulation necrosis is to be distinguished from the sim- 
ple death of a part by the presence of a coagulated albuminous 
liquid which accompanies the transition from life to death in 
the cells and tissues. This liquid bears such a strong resem- 
blance to coagulated fibrin that one is tempted to consider 
them the same, except that the macroscopical and microscopi- 
cal examination proves that the coagulation is chiefly present 
in the interior of the cells and in other constituents of the tis- 
sues. The microscope shows a peculiar homogeneous tendency 
of the cell-protoplasm, accompanied by a total disappearance 
of the nucleus. Thus the cells lose their sharp outline and be- 
come flaky masses, inclined to adhere to each other and fall 
into large irregular formations of membranous consistency. 
The frequent wax-like appearance of these coagulations is a 
peculiar feature, indicating their thorough impregnation with 
a strong refractive albuminous body." 

Yirchow divided the process by which false membrane is 
produced, and the resulting false membranes themselves, into 
two principal classes, the croupal and the diphtheritic. Croupal 
1 " Elements of Pathology." 



PATHOLOGY. 



49 



false membrane may be roughly stated to be that which lies 
superficially and loosely upon the mucous membrane affected, 
and is mainly a fibrinous exudation; the diphtheritic that 
which penetrates it more or less deeply, and is in reality an 
eschar in it or even beneath it. This classification is now gen- 
erally admitted to be based on differences in degree and in ana- 
tomical relations rather than in essential pathological nature. 

Ziegler describes the various processes by which false mem- 
brane is formed and their products, according to views now 
prevailing, with such clearness that I shall quote from his 
statements : 

"Croupous Inflammation. 1 — When a mucous membrane 




Fig. 5.- Croupous Membrane from the Trachea. (X 250.) a, section through the false 
membrane; b, upper layer of the mucous membrane, infiltrated with pus-corpuscles (d); c, 
filaments and granules of fibrin; d, pus-corpuscles. 



is so injured that its epithelium is here and there partially de- 
stroyed, and at the same time its blood-vessels are so damaged 
that an abundant exudation is poured out on the surface, co- 
agulation of the latter may take place. In this way a pale 
yellowish membrane is formed on the surface, consisting of 
fibrinous filaments and granules beset with pus-corpuscles, or 
of shining homogeneous blocks representing cells which have 
undergone coagulative necrosis. This false membrane is con- 
nected with the underlying structures by fibrinous threads, 
but is usually loosely adherent and can be readily stripped off, 
disclosing the red hypersemic mucous membrane beneath. 

1 " Text Book on Pathological Anatomy and Pathogenesis," Section 423. 
4 



50 



diphtheria: its nature and treatment. 



The epithelial cells are always more or less injured, being either 
necrotic or in process of degeneration and desquammation. 
The fibrous structure of the inflamed mucous membrane al- 
ways contains liquid and cellular exudations. 

"Diphtheritic Inflammation. — When a mucous membrane 
is injured in such a way that its epithelium dies without des- 
quamation, while its blood-vessels are damaged and pour out. 
an abundant exudation, it sometimes happens that the dead 
epithelial cells become saturated with the exuded liquid and 

9 •? 




e J* e 

Fig. 6. — Section through the Uvula in Diphtheritis Faucium. (Aniline-brown staining; 
X 75.) a, normal epithelium; b, normal areolar tissue; c, necrosed epithelium transformed 
into a coarse mesh-work; d, areolar tissue infiltrated with fibrin and leucocytes; e, blood- 
vessels; /. haemorrhage; g, heaps of micrococci. 

then pass into a peculiar condition of rigidity akin to coagula- 
tion. The seat of this change appears to the naked eye as a 
dull grayish raised patch surrounded b}^ red and swollen mucous 
membrane. The exudation is rich in albumen and the trans- 
formed cells take on the appearance of a kind of coarse mesh- 
work almost or altogether devoid of nuclei. The sub-epithelial 
areolar tissue is beset with filaments of fibrin and leucocytes. 
Haemorrhages are not uncommon. Inflammations of this 
kind, in which the tissue itself coagulates into a solid mass, are 
called diphtheritic. When the necrosis and coagulation extend 



PATHOLOGY. 51 

only to the epithelium we may speak of the process as super- 
ficial diphtheritis. It is by no means necessary " either in 
croupous or in diphtheritic inflammation, " that the whole of 
the epithelium should perish at the outset; some part of it at 
least may perish secondarily in consequence of the inflamma- 
tion." 

The anatomical and histological distinction between the 
croupous and the most superficial form of diphtheritic false 
membrane is, therefore, that the former consists mainly of 
coagulated fibrin and lies superficially over the epithelial cells 
(sometimes among or beneath them) being connected to the 
mucous membrane only by filamentous attachments which are 
easily broken ; while the latter, even when superficial and thin, 
consists mainly of transformed epithelium which remains in 
close apposition to the inflamed living tissues beneath it, so that 
if it be torn from them or destroyed by chemical agents a raw 
and bleeding surface is exposed. 

" Deep or parenchymatous diphtheria is characterized by 
the coagulation, not merely of the epithelium but also of the 
underlying connective tissue. The epithelium in some cases is 
lost altogether, and then the diphtheritic patch consists of 
dead connective tissue only. The patch is turbid and granular 
in texture, or it may be homogeneous or composed of amor- 
phous hyaline blocks. The nuclei are always more or less com- 
pletely lost. The small vessels which permeate the patch show 
signs of a homogeneous transformation of their walls. The 
dead tissue is separated from the living by a zone of cellular 
infiltration. Fibrinous filaments are seen here and there 
through the mass. The lymphatics in the neighborhood con- 
tain coagula and leucocytes." (See Fig. 7.) 

Oertel 1 in his latest work presents with great minuteness 
and detail the results of his researches into the histological 
changes which occur in diphtheria. These consist primarily 
and essentially in a characteristic degenerative metamorpho- 

1 " Die Pathogenese der Epidemischen Diphtheric." Leipzig, 1887. 



52 



diphthekia; its nature and treatment. 



sis in the cells and their nuclei. This takes place especially in 
the cells " which are derived from the white blood corpuscles, 
and are known under the collective name of leucocytes." The 
nucleus shows signs of retrogressive metamorphosis. The 
nuclear membrane breaks up; the nuclear and the cellular 
substance run into one mass, and the different forms of chro- 
matin undergo a similar change. The longer this process has 
continued the fewer are the colorable fragments of nucleus, 
vesicles, granules, etc. The nuclei or granules exhibit peculiar 




Fig. 7. — Section of the Uvula in a Case of Diphtheritis Faucium. (The epithelium has 
been shed ; aniline-brown staining ; X 100) a, micrococci ; b, submucous tissue changed into 
amorphous blocks ; c, extravasated leucocytes ; d, fibrinous exudation ; e, blood-vessels ; /, 
lymphatic vessel containing cells and fibrin. 



forms, as if ligatured and partially divided in two; free nuclear 
and granular vesicles are seen, and others which are connected 
by minute threads. The protoplasm and the nuclei are trans- 
formed into a homogeneous fluid and finally coagulating sub- 
stance. 

Explanation op Figure 8. — Section of a Diphtheritic Pharyngeal Mucous Membrane. 
False membrane invade. 1 by typical rod-shaped bacteria. Cells in different stages of de- 
composition and division. Necrosis of these cells and of the upper layers of the mucous 
membrane. Advancement of normal cells from the deeper layers, a, necrotic zone; b, dis 
eased zone; c, apparently normal tissue; F.N., fibrinous network; B. Y. , bacterial vegeta- 
tions; K.B , vesicular nuclei with parietal arrangement of colorable nuclear substance; 
Z. K., granular detritus; Sch., mucous membrane; d.A., direct division of the nuclei, as if 
by ligature, ("Kernabschnut•ung , "); i.F., cells with indirect nuclear fragmentation — Poly- 
morphous nuclei; L, leucocytes in the deeper layers of the mucosa and submucosa. 




,y-^t-::- H' :■'■•;- '3ta -'■■■■■■■■■: - W-,:.:.:, ry%\ ■■■<s^ i .': ^ .-i 

w Jit- ■ -^ ■ ;: ' :: ^^ L 



; '■■■■ " •"' v' v 'Jr v * :: 

'■$^\-i- . ■'■ .-. . v ' « ■-■".• : « 










and Uvula. 



5-1 diphtheria; its nature and treatment. 

This change is not a purely chemical one, but is also the re- 
sult of the action of the serous and fibrogenous lymph which 
has exuded with the white corpuscles from the blood-vessels. 

The coagulation of this substance upon a free surface or 
within the interstices of the mucous membrane or of the tis- 
sues beneath it, with an accompanying' hyaline metamorphosis 
of cells, vessels and tissue-fibres, constitute false membrane, as 
has been already described. 

The characteristic cell-changes referred to are seen not only 
in false membranes and the subjacent tissues in every situa- 
tion, but also wherever the diphtheritic poison has penetrated, 
and in a degree proportioned to the directness and intensity of 
its action — in the tonsils and the lymphatic glands, and less 
uniformly and typically in more remote organs, as the stomach 
and intestines, the heart, the spleen, etc. 

The absence of the characteristic lesions in the lungs is 
opposed to the hypothesis of a primary infection of the system 
through those organs. 

The inauguration and extension of the diphtheritic process 
are described as taking place in the following manner : The 
diphtheritic virus irritates the epithelium and the uppermost 
layers beneath it, occasioning a profuse emigration of leuco- 
cytes. These cells, which have come as a protection, absorb 
the virus and become diseased, undergoing the necrobiotic 
changes which have just been described. Cells of various sizes 
press forward to take up the struggle with the invading poi- 
son — among them the large protoplasmic cells which are called 
phagocytes. Thick and dense layers of these cells form far 
under the epithelium and fill the whole mucosa, many of which 
sho w great alterations in their nuclei. These have undoubtedly 
taken up poison during or soon after their emigration from 
the blood-vessels, and have become diseased. They soon fall 
into a state of necrobiosis, and the result of these multiple ne- 
crobiotic processes and the irritation which they excite is the 
renewed accumulation of fresh cells, which in turn are exposed 



PATHOLOGY. 55 

to the ever-increasing- poison and are destroyed in great num- 
bers. The formation of extensive necrobiotic masses or depots 
in and beneath the mucosa is the result of these occurrences. 

In connection with the morbid appearances which accom- 
pany diphtheritic inflammation various kinds of bacteria have 
in many cases been observed on the surface of, and within, the 
false membranes and in the underlying tissues and vessels, as 
has been stated in the chapter on etiology. 

The inflammatory processes which have been described oc- 
cupy a various length of time in reaching their completion; 
the croupous sometimes does this by throwing out successive 
exudations, which produce distinct layers in the resulting false 
membrane. This membrane gradually becomes macerated and 
its filamentous attachments to the mucous membrane weak- 
ened by muco-purulent secretion beneath and around it, so 
that it becomes detached either in minute or larger portions. 

The diphtheritic inflammation may terminate quickly with 
the production of a limited and superficial necrotic patch, or it 
may persist for some time, causing' the death of deeper and 
deeper portions of the epithelial, the mucous and the sub-mu- 
cous tissues, the interpenetrating fibrinous network and bands 
being reinforced by repeated vascular exudations, and an in- 
tense purulent inflammation being excited in the subjacent and 
surrounding tissues. When the diphtheritic process has ceased, 
the patches or sloughs, as foreign bodies, keep up irritative in- 
flammation beneath and around them. The superficial epithe- 
lial patches thus become infiltrated with pus and disintegrated 
or cast off, and the deeper sloughs are more tardily detached 
by suppuration and demarcative ulceration. In the former 
case the loss of epithelium is readily made good by the multi- 
plication of the epithelial cells which remain; in the latter a 
cicatrix results which in time becomes covered with new epi- 
thelium. 

In some cases the gangrenous form of necrosis is substi- 
tuted for the diphtheritic by the penetration into the diseased 



50 DIPHTHERIA; ITS NATURE AND TREATMENT. 

tissues and the rapid multiplication in them of the bacteria of 
putrefaction. 

Either of the forms of inflammation above described may 
occur on any mucous membrane. This fact shows that the' 
occurrence of either is sometimes determined by the nature 
and intensity of its exciting- cause indepenclentry of local ana- 
tomical conditions. Yet as a general rule the occurrence of 
one or the other form of inflammation is decided or greatly in- 
fluenced by the anatomical peculiarities of the mucous mem- 
brane upon which it is developed. 

The mucous membrane of the mouth, the pharynx and the 
oesophagus is covered with thick pavement epithelium which 
lies immediately upon the connective tissue of the mucosa 
without the intervention of a basement membrane. These 
conditions seem to favor the limitation in area of pseudo-mem- 
branous inflammation and its deep penetration, when it has 
once gained a foothold, rather than its rapid superficial exten- 
sion and the throwing- out of exudations upon the surface. 

The epithelium of this region, when in a healthy state, is 
probably impermeable by bacteria. An exception to this con- 
dition has been demonstrated by Ph. Stohr, in the case of the 
tonsils, the epithelia of which show minute cracks or loop-holes 
through which round cells emigrate, and through which, pre- 
sumably, micro-organisms may find entrance — a fact which 
may in part explain the especial receptivity of these organs to 
the diphtheritic infection. 

The oro-pharyng-eal mucous membrane is in most parts 
abundantly supplied with blood-vessels and lymph- vessels, the 
latter of which empty into various glands in the neck and 
face, the principal exception being the tonsils, in which both are 
comparatively few. This peculiarity again may explain the 
fact that while tonsillar diphtheria is the commonest it is the 
least productive of general infection. 

The mucous membrane of the nasal passages, except in the 
nostrils, and of the air passages, except on the true vocal cords 



PATHOLOGY. 57 

and the aryteno-epiglottic fold, is covered with cylindrical epi- 
thelium. This is separated from the subepithelial tissues by a 
basement membrane which is their uppermost layer. These 
anatomical conditions favor the " croupous " form of inflam- 
mation. 

" Croupous " and " diphtheritic " inflammation, as above 
described, do not always result from infection, but may be the 
effect of a variety of other causes. Among- these causes are in- 
juries from chemical, thermal and physical agencies. 

In Guy's Hospital Reports for 1877 Dr. Hilton Fagge re- 
ported eleven cases of membranous laryngitis, with or with- 
out pharyngitis, which were directly caused by local injury to 
the throat, the injuries being scalds by hot water, the entrance 
of a foreign body into the trachea, a cut throat, and trache- 
otomy for various conditions. Dr. Fagge remarks upon these 
cases 1 that " they negative the a priori argument that the 
mucous membrane of the air-passages is not likely under 
simple (or non-specific) irritation to take on an inflammatory 
process attended with the formation of false membrane." 

In the report last referred to (page 95) an interesting and 
instructive case is related which was communicated by Dr. 
Whitehead Reid. In the application of a bottle of eau-de-Co- 
logne to the nostrils of a lady who had fainted, a portion of the 
liquid flowed through her left nostril into her throat. Symptoms 
of intense pharyngeal, nasal and laryngeal inflammation im- 
mediately followed. On the third day false membrane ap- 
peared in the pharynx and the left nostril. Pieces of mem- 
brane were several times coughed up. At length on the fifth 
day a perfect cast of the larynx, the trachea and the upper 
part of the left bronchus, was expelled entire with immediate 
relief to the vocal and respiratory symptoms, and the temper- 
ature soon fell below the normal. Small pieces of membrane 
continued to be coughed up, and membrane remained in the 

1 Report of Committee of the Royal Med. and Chirurg. Society, 1878, 
on the relations of Membranous Croup and Diphtheria. 



58 DIPHTHERIA; ITS NATURE AND TREATMENT. 

left nostril until the seventh day. The lady subsequently made 
a complete recovery. There was never any albumen in the 
urine; no paralysis followed. She had been exposed to no 
scarlatinal or other poison. There was no diphtheria in the 
village. Neither of her young 1 children, who were constantly 
with her, became ill. On microscopic examination the constit- 
uents of the expelled cast were found to be identical with those 
usually found in croupous pseudo-membrane occurring in those 
localities. 

Many instances are on record of the production of croup- 
membrane in the throats and air-passages of horses and cattle 
by their inhaling smoke and heated air in burning stables. 

Pseudo-membrane has been artificially produced in the 
trachea of animals by many experimenters by the application 
of various chemical irritants; by Bretonneau by means of 
tincture of cantharides and olive-oil. and subsequently by Tren- 
delenberg, Oertel, Wood and Formad,Weigert and many others 
by the application of ammonia, corrosive sublimate, arsenic, 
chlorine, carbolic acid, etc. The pseudo-membranes thus pro- 
duced have been found by most of the investigators referred 
to to be identical in all discoverable physical and chemical 
particulars with those ordinarily occurring in disease. 

Dr. O. Heubner, 1 following the discovery of Cohnheim and 
Litten, that coagulative necrosis may be produced in a portion 
of mucous membrane by temporarily cutting off its blood- 
supply, selected as the most suitable one for his experiments, 
for anatomical reasons, that of the fundus of the urinary blad- 
der of the rabbit. By ligating the neck of the organ the cir- 
culation was completely arrested. The ligature was removed 
after two hours, when the circulation was restored in those 
vessels which were free from thrombi. The result of the oper- 
ation was, first, a swollen hemorrhagic cedematous condition 
of the mucous membrane, the epithelium being loosened and 
its more superficial layers enlarged; and by the second and 
1 Die Experimentelle Diphtheric Leipzig, 1883. 



PATHOLOGY. 59 

third day, in patches, a necrotic transformation of the epithe- 
lium, the mucous membrane and the submucous tissues into a 
firm yellowish layer which was morphologically identical with 
true diphtheritic membrane. The steps in this process are, 
first, necrotic changes in the cells and other constituents of the 
tissues, including- lesions in the walls of the blood-vessels from 
inanition during the interruption of their blood-supply ; second, 
the current being restored, inflammatory exudation through 
the dead and dying tissues, the result of the vascular lesions, 
the diphtheritic process being thus seen to be a nicely adjusted 
combination of necrosis and inflammation, in which the tissue 
elements must be dead or in process of dying, and the blood- 
vessels also injured but not yet dead or occluded. 

The process of pseudo-membranous formation resulting* 
from either of the causes just referred to seems to be an en- 
tirely local disease, and neither accompanied with constitu- 
tional poisoning* nor communicable to others. Heubner found 
his diphtheritic products uninhabited by any bacteria except 
accidental ones, and they were inoculated into other animals 
without result. 

The facts just referred to have an obvious bearing on the 
mooted question of the identity or diversity of membranous 
croup and diphtheria, or, more precisely stated, the question 
whether all cases of membranous croup are cases of diphthe- 
ria. They place it beyond doubt that pseudo-membranous 
croup, in the histological and anatomical sense of the term, is 
a condition which may be excited by a variety of causes, of 
which diphtheritic infection is only one. 

In the clinical sense, however, as described by many author- 
ities, simple membranous croup is a non-infectious phlegmasia 
of the laryngeal or the laryngo -tracheal mucous membrane, 
and is the result of meteorological conditions, which act upon 
it either as direct irritants or indirectly through the organism 
by the series of reflexes known as "catching cold." By far 
the more usual effect of this class of causes upon the mucous 



60 diphtheria; its nature and treatment. 

membranes is the production of catarrhal inflammation. That 
they should excite instead croupous inflammation in excep- 
tional instances is explained by the supposed especial inten- 
sity of the irritation produced in those cases and by individual 
predisposition. 

Testimony to the effect that not a few cases of pseudo- 
membranous laryngitis have occurred, which were in no way 
traceable to diphtheritic or other infection, and followed ex- 
posure to cold, to cold and dampness, to sudden changes of 
temperature or to cold winds, which were accompanied with 
no evidence of constitutional diphtheritic poisoning* nor com- 
municated contagion to others, abounds in medical literature 
since the time of Home. Much of it, when examined by the 
light of our present knowledge of the diseases in question, 
must be rejected; but not a little remains which is so precise 
in character and from such competent sources that it cannot 
reasonably be doubted. 

Statistics seem to show a much more direct etiological 
relation between meterological conditions and membranous 
croup than between them and diphtheria. In a large aggre- 
gate of fatal cases of membranous croup collected by Hirsch 1 
the number occurring between October and March is to those 
occurring in the warmer half of the year nearly as two to one 
— a much larger ratio than that in the case of diphtheria, as 
showm in the chapter on etiology. The gross inaccuracy of 
the nosological classification in most such statistics must be 
conceded; but the difference referred to would probably be 
greater rather than less w T ere they more accurate. 

From the opposite point of view it is argued that some ap- 
parently typical cases of membranous croup proA~e to be cases 
of diphtheria by developing in their later stage, if they last 
long enough, the constitutional symptoms of diphtheria, and 
that others have been followed b} r cases of unquestionable 
diphtheria which w T ere evidently due to their contagion; that 

l Op. cit., p. 62. 



PATHOLOGY. 61 

the absence of diphtheritic constitutional poisoning in other 
cases may be due to their short duration before death is caused 
by asphyxia, and also to the fact that for anatomical reasons 
absorption of poison takes place much less readily from " croup- 
ous " inflammation in the larynx and trachea than from diph- 
theria in the pharynx or nares; that membranous laryngitis is 
of very frequent occurrence in connection with diphtheria, and 
is sometimes its initial manifestation, and that apparently 
typical cases of membranous croup occur with especial fre- 
quency in some epidemics of diphtheria. 

The truth of all these statements and their force as argu- 
ments are unquestionable; yet it seems very doubtful if they 
can be made to apply to or fco explain all of the cases originally 
referred to. Moreover, it seems a very probable supposition 
that a particular case of disease, occurring in places in which 
diphtheria is endemic or epidemic, or in which septic influences 
are present, may begin as a local non-infectious membranous 
croup and subsequently become infected by those agencies and 
thus converted into true diphtheria, since croupous inflamma- 
tion must furnish an especially favorable soil for such infection. 
Again, the view that there is a membranous croup which is not 
due to diphtheria is strongly favored by the occurrence of the 
rare analogous affection, idiopathic, fibrinous or croupous 
bronchitis, which seems to be due to the causes of catarrhal 
bronchitis, plus an individual predisposition, and cannot be 
supposed to be, in all cases at least, a form of diphtheria. 

Yirchow, in 1885, restated to the Berlin Medical Society 
that he had never been able to admit that all cases of fibri- 
nous laryngitis and tracheitis were due to diphtheritic poison. 

A final answer to the question under consideration can only 
be the result of a fuller knowledge than we at present possess ; 
but the facts which we have seem to me to establish a basis of 
strong probability for the following conclusions : Membranous 
croup, as above described, and diphtheria are two distinct 
affections. Simple membranous croup is a comparatively rare 



62 DIPHTHERIA; ITS NATURE AND TREATMENT. 

form of disease. In regions in which diphtheria is endemic or 
epidemic the two affections are so liable to he inter-complicated 
or confounded that the distinction is practically valueless. 

In folio wing the progress of diphtheria from local to gen- 
eral we have to note first the evidences of the entrance of poi- 
son from the seat of the local affection into the lymphatic and 
vascular systems. Penetrating the lymphatic vessels to the 
lymphatic glands, it produces inflammation in them, and this 
inflammation is to be observed in the glands which are thus 
directly connected with the part primarily affected. The 
glands are affected in various degrees, from a slight enlarge- 
ment to an intense inflammation of the glandular structures 
themselves, and of the peri-glandular connective tissue. They 
are found on examination to be in a state of vascular engorge- 
ment and cellular hyperplasia, and the surrounding tissues 
cedematous and infiltrated with pus cells and occasional extrav- 
asations of blood. 

The absorption of poison occurs mainly through the lym- 
phatics, but evidently in some cases takes place through the 
capillary blood-vessels, as is evidenced by the fact that tox- 
aemia is occasionally rapidly developed when there is little or 
no adenitis. 

The blood is changed in color and in consistency in a con- 
siderable proportion of fatal cases. The cause and nature of 
these changes are not fully known. In a majority of instances 
the change is to a darker color and more fluid consistency 
than in health; in a smaller number it is to a brownish color 
and a turbid condition, in which it communicates a stain like 
sepia. After death from asphyxia the dark color may be due 
to an excess of carbonic acid. When it is the result of tox- 
aemia it has been attributed in part to the debris of the disin- 
tegrated red corpuscles. A marked increase in the number of 
white corpuscles has been observed in some cases. There is 
also in the general disintegration of the constituents of the 
blood a diminution in the amount of fibrin. 



PATHOLOGY. 63 

Coagula are found in the cavities of the heart in many 
cases. These differ in form, size, structure, color and position. 
Some are said to have in these respects the distinguishing 
characteristics of ante-mortem clots. 

Dr. Beverley Robinson, 1 as a result of many careful obser- 
vations, regards these formations as a frequent cause of death. 
His observations are corroborated by others, as by W. C. 
Chaffey, M.B., 2 who states that in twenty-three post-mortem 
examinations in diphtheritic cases made during the previous 
two and one half years at the Children's Hospital in Great 
Ormond Street, London, more than one half showed marked 
fibrinous deposits, "probably all ante-mortem." The great 
majority of authorities, however, including Cornil and Ran- 
vier, 3 Sanne, 4 Cadet de Gassicourt, 5 and A. L. Loomis 6 believe 
that these coagula are not peculiar to diphtheria, but are 
formed under very various circumstances during the death 
agony, and are the effect rather than the cause of the cessa- 
tion of cardiac action. 

Coagula are also found in the large veins and sinuses. 
Hemorrhagic infarctions, the result of emboli, occur in many 
situations — in the subcutaneous connective tissue, beneath the 
pericardium, and in the muscular tissue of the heart, in the 
lungs, etc. Venous thromboses are seen in the substance of 
the brain and its investments, the liver, the spleen and other 
organs. 

The heart is often healthy in appearance, but in some cases 
important changes are observed. Among these are the effects 
of myocarditis. The muscular fibres are found to have under- 
gone granulo-f a tty degeneration, and to have become of softish 
consistency and of a light brownish or grayish color, and to 

l " These de Paris," 1872. 

2 British Medical Journal, July 16, 1887, p. 121. 

3 " Manuel d'histologie pathologique. " 

4 Op. cit., p. 105. 

5 "Maladies de l'Enfance," t. iii. 

6 Medical News, Nov. 10, 1888, p. 539. 



64 diphtheria; its nature and treatment. 

contain scattered extravasations of blood. These changes 
may be general or may be limited to a few fibres, and may 
occur in any portion of the heart-walls or in the columnse car- 
nese. Their effect is, in proportion to their extent and their 
degree of advancement, to produce dilatation and weakness of 
the heart. 

Endocarditis occurs in some cases of diphtheria as of other 
acute infectious diseases, but is not a frequent complication. 
It results in vegetations and fibrinous deposits on the valves, 
especially the upper surface of the mitral valve. These are 
easily detached and may become the sources of the widely dis- 
tributed emboli already referred to. 

The lungs are subject in diphtheria to a great variety of 
changes. These are mostly observed, however, in those cases 
in which death has resulted from croupal asphyxia. Among 
the morbid conditions which are most frequently met with are 
simple and pseudo-membranous bronchitis, broncho-pneumo- 
nia, pulmonary congestion and emphysema ; more rarely lobar 
pneumonia, pulmonary oedema, pulmonary apoplexy, pulmo- 
nary gangrene. 

Catarrhal bronchitis is in the majority of cases the accom- 
paniment of laryngeal diphtheria, but is not infrequently as- 
sociated with the pharyngeal and nasal forms. 

Pseudo-membranous bronchitis in diphtheria is in nearly 
all cases the extension downward of the laryngotracheal 
affection, though in rare instances the bronchial tubes alone 
are affected. 

Broncho-pneumonia, in its various forms and degrees, is of 
very great frequency in the laryngeal form of diphtheria, 
and is especially common in connection with bronchial diph- 
theria. 

Pulmonary congestion is also very common in connection 
with laryngeal diphtheria, usually occupying the lower and 
posterior portion of one or both lungs ; the upper and anterior 
portions are as frequently emphysematous. 



PATHOLOGY. 65 

The liver is usually unaltered, but is occasionally en- 
larged and congested or affected with waxy or fatty degen- 
eration. 

The spleen is usually normal, but may also be enlarged and 
softened. 

The kidneys are the seat of the most frequent and important 
secondary changes occurring in diphtheria, but these changes 
are not peculiar or characteristic. The kidneys are affected 
in most cases which terminate fatally from systemic poisoning ; 
and they exhibit every degree of affection from a slight hyper- 
emia to the most intense inflammation. The most usual form 
of nephritis in diphtheria is the parenchymatous, but the inter- 
stitial is not infrequent. 

The brain, in cases in which death has resulted from croup, 
exhibits venous engorgement in its substance and its mem- 
branes and extravasations of blood— the results of asphyxia. 
Serous effusions of the meninges and into the ventricles, pus 
and lymph on the arachnoid membrane, or a granular condi- 
tion of the white substance of the brain, have been observed in 
cases in which there had been grave septicaemia and albumi- 
nuria with cerebral symptoms. 

In some observations after death from diphtheritic paraly- 
sis, no appreciable changes in the nervous system have been 
discovered. In some cases there have been various degrees 
of hyperemia in the brain and spinal cord, with minute 
extravasations of blood, or in rare instances larger ones into 
their substance, and in some cases meningeal congestion with 
or without hemorrhages about the nerve roots. 

The lesions which are characteristic of diphtheritic paraly- 
sis are only revealed by the microscope, and are found in the 
peripheral nerves which supply the parts affected, in the gray 
matter of the anterior cornua of the spinal cord, and in severe 
cases of long duration in muscular fibres, especially in the soft 
palate, but occasionally in the extremities. 

The peripheral lesions were first observed by Charcot and 



bb diphtheria; its nature and treatment. 

Vulpian 1 in a case of paralysis of the velum palati. Some of 
the muscular fibres in that organ were in a state of fatty de- 
generation. In the muscular nerves some of the fibres con- 
sisted of tubules emptied of their medullary substance. The 
neurilemma contained in some places numerous granular bodies 
with or without nuclei. Lorain and Lepine found similar 
changes in the soft palate, and Liouville in the phrenic nerves. 
Buhl 2 in one case found hemorrhages in the cerebral pia mater 
and cortex, infarcts in many parts of the brain and spinal cord, 
and the spinal ganglia and nerve-roots swollen, the swelling 
being due to infiltration of the nerve sheaths and the intersti- 
tial tissue with nuclear bodies which he considered character- 
istic of diphtheritic inflammation. Ley den found in one case 
appearances of a "neuritis migrans " ascending toward the 
nerve centres as far as the medulla oblongata ; Oertel 3 in one 
case multiplication of nuclei in the gray substance of the spinal 
cord, especially in the anterior cornua, and hemorrhagic patches 
in the cord and pia mater; Vulpian 4 in three cases "rarefac- 
tion " of connective tissue in the anterior horns, with altera- 
tions in the motor nerve-cells and slight increase in the number 
of nuclei in the spinal cord ; Pierret 5 in one case disseminated 
patches of spinal meningitis with peri-neuritis of nerve-roots. 
Dejerine 6 found in five cases constant changes in the ante- 
rior cornua with consecutive neuritis of the corresponding an- 
terior spinal nerve-roots. The affected nerve cells were swollen 
in some instances, in others shrunken, were indistinct, had l@st 
their processes and were globular in shape. The number of 
nerve -cells in certain portions of the anterior cornua was di- 
minished. The small vessels were distended with blood and 
dilated, and hemorrhages from their rupture were observed in 

'Compt. rend, de la Soc. de Biol., 1862. 

2 Zeitsch. f. Biol., 1867. 

3 Deutsches Arch. f. Klin. Med., viii., 1871. 

4 Malad de Syst. Nerv., 1870. 

5 Compt. rend, de la Soc. de Biol., 1876. 

6 Arch, de Phys. norm, et path., t. v., p. 107, 1878. 



PATHOLOGY. 67 

the anterior cornua together with perivascular collections of 
small cells. Around the central canal there was cell-infiltra- 
tion of an inflammatory nature. Dejerine regarded this affec- 
tion of the spinal cord as subacute tephro -myelitis, the accom- 
panying- neuritis of the anterior spinal roots being secondary 
to the spinal lesion. 

Gaucher * in one case found changes in the anterior cornua 
and nerve-roots identical with those described by Dejerine. 
Abercrombie 2 in seven cases, Percy Kidd 3 in one case, and Dr. 
Mott of Liverpool, as reported by Percy Kidd, in one case, in 
which only the brain and spinal cord were examined, also 
found similar lesions in the latter to those described by Dejer- 
ine. Meyer 4 in one case found inflammatory changes in the 
gray matter of the anterior and posterior cornua of the spinal 
cord, degeneration of spinal roots and neuritis in phrenic and 
muscular nerves. Pitres 5 in one case found parenchymatous 
neuritis of the peripheral nerves and spinal roots with no 
alteration in the spinal cord. Mendel 6 in one case found marked 
congestion of small arteries of the brain;, capillary hemor- 
rhages in pons, medulla, and near the nucleus of the oculo-motor 
nerve; neuritis of peripheral nerves, especially the oculo- 
motor, abducens, and vagus. 

1 Journ. de Tana/tom. de Robin, 1881. 

2 Trans. Internat. Med. Cong., 1881. 

3 Med. Chir. Trans., lxvi., 1885, p. 136. 
4 Virch. Archiv., vol. lxxxv., p. 181. 
5 Arch. de. Neurol., 1886, xi., p. 337. 
6 Berliner Klin. Wochenschr. , 12, 1885. 



CHAPTER IV. 

SYMPTOMS. 

Diphtheria is classed according- to its localization as 
pharyngeal, nasal, laryngeal, ocular, vulvar, cutaneous, etc. 

According- to its intensity, as mild, severe and malignant. 

According- to the degree of toxic absorption, as benign and 
septic. 

According- as it is idiopathic or supervenes upon other dis- 
eases, as primary, or secondary. 

Diphtheria has many complications. These may be mainly 
due either to the mechanical interference of the false mem- 
brane with respiration; as is seen in certain pulmonary com- 
plications of diphtheritic croup, or to hgemic poisoning, as is 
seen in the morbid affections of the kidneys, the heart and other 
organs. 

Diphtheria has also certain sequelae, the most important 
and characteristic of which is paralysis. 

Diphtheria of the Pharynx and Soft Palate. 

The pharynx is by far the most usual site of diphtheritic 
inflammation. Not only are a large majority of all diphthe- 
ritic attacks limited to this locality, but in a great proportion 
of all cases in which the larynx, the nasal passages or the 
mouth are invaded, the pharynx is also affected either prima- 
rily or secondarily. 

No portion of the pharynx is so often affected as the tonsils. 
In thirty-eight cases accurately described by me, 1 the location 

1 New York Med. Record, March 27th, 1880, p. 340. 



SYMPTOMS. 69 

of diphtheritic membrane was as follows: tonsils only, 11 ; ton- 
sils and velum palati, 3; tonsils and nares, 4; tonsils, soft pal- 
ate and nares, 8; tonsils and tongue, 1; tonsils, nares, uvula 
and gums, 1 ; tonsils, nares, soft palate and tongue, 1 ; tonsils, 
nares, soft palate, tongue and lips, 1; tonsils and larynx, 1; 
tonsils, soft palate and larynx, 4; uvula, 1; velum, 1; uvula 
and nares, 1 ; showing the tonsils to have been affected in 
thirty -five out of thirty-eight cases. From my observation of 
much larger numbers of cases of which my records are less 
complete, I think that this distribution is about an average 
one, except that in some epidemics the proportion of laryn- 
geal cases would be much greater. 

The Catarrhal Stage. 

The symptoms of the initial stage of pharyngeal diphtheria 
differ in no respect from those of the same stage of other forms 
of sore throat. As in them, there may be for a 'period varying 
from a few hours to several days feelings of depression, slight 
chilliness, feverishness, anorexia, nausea, headache, slight pains 
in the neck, back or extremities. A pronounced chill is less 
usual, but sometimes occurs. In children of highly suscepti- 
ble nervous organization there may be convulsions. 

The temperature is elevated from one to several degrees, 
and the pulse is correspondingly accelerated. 

At this stage of the disease, and as its first noticeable 
symptom, there are often pain and difficulty in swallowing, 
but sometimes there is an entire absence of subjective throat 
symptoms. 

If the throat be inspected, however, it will invariably be 
found to be more or less reddened and congested. This ap- 
pearance may be general, but more usually is limited or un- 
equal, affecting especially one tonsil and its immediate sur- 
roundings, or one of the faucial arches and the uvula, .or a well- 
defined patch on the anterior surface of the soft palate. 



70 diphthekia; its nature and treatment. 

The Stage of Pseudo-Membranous Formation. 

The transition from the catarrhal stage to the croupous or 
the diphtheritic, when watched, is seen to consist in a gradual 
deepening of the angry redness in one or more patches of the 
mucous membrane, and then the appearance upon them of dots 
or streaks of a pearly or yellowish whiteness. These multiply, 
extend and coalesce over the affected surface until it is covered 
with a smooth, glistening layer (" croupous "), the margin of 
which is surrounded with a red or purplish ring. Or yellow- 
ish spots appear on the surface of the mucous membrane, and 
then become more and more definite and opaque, until their 
aggregation assumes the appearance of a patch of yellow or 
gray chamois leather imbedded in the intensely inflamed tis- 
sues ("diphtheritic"). The exudative deposit or the necrotic 
change thus occurring may soon reach its completion, with a 
moderate degree of surrounding inflammation and febrile dis- 
turbance, or with a persistence and intensification of both it 
may continue to extend by an enlargement of the patches al- 
ready formed, or the appearance of additional ones. 

The pain in the throat is sometimes so slight that the real 
nature of the ailment is unsuspected until it is revealed by 
inspection; but it more usually varies from a sense of stiffness 
or pricking to a most acute distress on swallowing. 

Vomiting is a frequent symptom, and at this stage of the 
disease is usually a reflex from the faucial irritation, as when 
the throat is tickled with a feather. I have seen it to be par- 
ticularly liable to occur when the uvula is the seat of diphthe- 
ritic inflammation. 

The throat is filled with mucus, which, at first white and 
tenacious, becomes more and more purulent and sometimes 
reddish or streaked with blood from hemorrhagic points in the 
inflamed mucous membrane. 

Foetor in the breath, slight at first, becomes more and more 
noticeable. 



SYMPTOMS. 71 

Adenitis may be so slight as to be scarcely perceptible, or 
may rapidly become a prominent and formidable symptom. 

The temperature is now at its highest, and may vary from 
an elevation of one or two degrees above the normal to 105° or 
106° F. It is usually in direct proportion to the intensity of 
the inflammation in the mucous membranes, the sub-mucous 
tissues and the glands. 

The acceleration of the pulse at this stage of the disease is 
usually in proportion to the rise in temperature, and sometimes 
exceeds that proportion. There are in some cases other quali- 
ties to be noted besides its rapidity. It may be small, thready, 
irregular or flickering. This is usually in cases in which there 
is a rapid onset of throat inflammation and adenitis, with acute 
f aucial pain and reflex nausea and vomiting. It is then the 
pulse of shock. The abundant nerve supply in the throat causes 
it to be the source, when irritated, of various remote reflex dis- 
turbances, and these may include the action of the heart. This 
point is important, because this quality of the pulse at this 
stage of the disease is often attributed to the essentially weak- 
ening effect of diphtheria, and therefore supposed to call for 
early and profuse stimulation. That this is not usually the 
case is proved by the fact, which I have often observed, that 
after the extension of inflammation has ceased and the attend- 
ing pain and nerve disturbance have abated the pulse returns 
to nearly its normal volume and regularity, although the 
process of constitutional poisoning peculiar to the disease 
may then have really commenced or become more advanced 
than before. 

The character of the disease at this stage is usually sthenic, 
though some of its symptoms may, as has just been pointed 
out, apparently indicate asthenia. Its essential feature is pro- 
gressive diphtheritic inflammation. Upon the extent and in- 
tensity of this inflammation depend not only the accompany- 
ing symptoms, but in most cases the subsequent type and 
gravity of the malady. 



72 diphtheria; its nature and treatment. 

Mild or Benign Form. — In this form the symptoms which 
have now been referred to are relatively moderate in degree 
and transient in duration. The temperature rarely exceeds 
104° F.; adenitis is slight; the swelling- of the throat is not 
very marked, though the tonsils may be considera bly enlarged. 
The false membrane is often limited to the tonsils, though it 
not infrequently covers more or less of the surface of the fau- 
cial pillars, the soft palate and the uvula. Its character is dis- 
tinctive, being invariabty comparatively superficial. 

Severe Form. — In this form, on the other hand, the symp- 
toms are usually correspondingly grave. The temperature 
may reach 105° or 106° F.; adenitis is commonly quite marked, 
and may be very great. The inflammation in the throat is 
more intense than in the other form, the swelling being greater, 
the redness of the mucous membrane deeper, and the false 
membrane usually, though not necessarily, more extensive — 
sometimes covering the entire pharynx and soft palate in one 
nearly continuous investment. Its character is also distinct- 
ive. Some portion of it,' at least, is of the deep or parenchy- 
matous variety. 

Further Course of the Disease and its Terminations. 

When the diphtheritic inflammation has reached its acme 
— usually from the second to the fourth day of the disease — 
the predominant symptoms undergo a change in two respects : 
There is, first, a subsidence of the febrile symptoms to the 
milder ones of a subacute inflammation which is mainly due 
to lesions already produced; and, second, the first appearance 
in some cases, and a notable increase in others of symptoms 
which denote constitutional infection. 

Mild or Benign Form. — This has two modes of termina- 
tion. Usually it is favorable. The faucial inflammation and 
the fever subside and do not return. The false membrane ex- 
foliates after from three to seven days' continuance, when the 
mucous membrane is seen to be only slightly hyperaemic, and 



SYMPTOMS. 73 

soon recovers its normal appearance. In rarer cases the dis- 
ease, after continuing- for some days in this form, suddenly, 
either from injudicious treatment or exposure to cold, or some 
cause which is not so obvious, takes on a new aspect— the 
diphtheritic inflammation becoming not only more extensive 
but more intense and deeper — and assumes the form next to 
be described. 

Severe Form. — In this form of the disease the more super- 
ficial portions of the false membrane may exfoliate in a few 
days as in the milder form ; but the deeper portions, sometimes 
very extensive, and sometimes only a single limited patch, 
continue after the rest has disappeared, impenetrable to ordi- 
nary antiseptic remedies, and causing far greater local irrita- 
tion and more profound constitutional poisoning than that has 
done. 

Nasal and oral diphtheria are very frequent complications, 
and add materially to the gravity of the disease. These will 
therefore now be described. 



Nasal Diphtheria. 

Nasal diphtheria is most usually secondary to pharyngeal 
diphtheria, making its appearance after the affection in the 
throat has existed for one or more days; yet in many cases it 
is primary, preceding the other or appearing at the same time 
with it. In some cases the disease is limited to the nasal 
passages throughout its course. 

When the affection begins too high up for the false mem- 
brane to be visible on inspection, its nature may be for a time 
uncertain, but it is usually soon recognizable by the degree 
of obstruction which it causes and by the character of the dis- 
charge from the nostrils. This becomes either thin and 
ichorous, or profuse, yellowish and muco-purulent. It is often 
very irritating, producing excoriation on the margins of the 
nostrils and the upper lip, which become coated with diph- 



74 

theritic membrane. There is also quite early a characteristic 
foetor. 

Epistaxis often occurs. This may result from capillary 
congestion or commencing- ulceration, and may follow picking 
or rubbing- the nose or maladroitness in administering- injec- 
tions, etc. It is then usually slig-ht or easily controllable. 
Later it may result from more extensive ulceration of the 
mucous membrane or from a hsemorrhagic tendency conse- 
quent upon the constitutional poisoning-, and is then profuse, 
persistent and difficult to control. I have never known of its 
being- the immediate cause of death, but the serious exsangui- 
nation which it produces when the system is already anaemic 
and enfeebled is doubtless in some cases the determining- cause 
of a fatal result. 

The chief importance and gravity of nasal diphtheria, how- 
ever, results from the fact that it is especially liable to be 
attended with constitutional poisoning- by absorption. This 
results from two causes : first, the Schneiderian membrane is 
abundantly supplied with absorbent vessels by means of which 
the poison is conveyed into the general circulation; and second, 
while the throat is washed by the saliva and by food and drink 
as well as medicines which are swallowed, there is no such 
provision of nature for the disinfection of the nasal passages. 

As a result of this toxic absorption adenitis is a usual ac- 
companiment of nasal diphtheria. Yet in some grave cases 
adenitis is only very slight. 

I have already stated that in rare cases diphtheria is limited 
to the nasal passages. When the posterior nares only are 
thus affected the nature of the disease is liable to be over- 
looked. Its presence may be suspected from the existence of 
symptoms of diphtheritic poisoning with those of post-nasal 
catarrh. 



symptoms. . 75 

Diphtheria of the Mouth. 

Diphtheria of the mouth is usually a complication of pha- 
ryngeal diphtheria. It often alights on points where abrasion 
of the epithelium or ulceration exists. In a case in which a 
too energetic nurse persisted, in spite of my remonstrances, in 
removing the secretions from the mouth of an infant suffering 
with diphtheria by wiping it out with a napkin, diphtheritic 
patches appeared on the tongue and the lips. In some in- 
stances, however, the mouth is the only region affected. Its 
most usual situation is the lips — either the angle at their junc- 
tion or the inside of the lower lip. In such cases the lip some- 
times becomes greatly swollen. Next in frequency to the lip 
diphtheria occurs on the tongue. In that situation it may 
be superficial and of transient duration, or deep and persistent 
and accompanied with great swelling. It occurs also on the 
gums and on the mucous membrane lining the cheeks. In 
those localities also it may be of very various degrees of depth, 
extent, severity and persistency, and attended with various 
degrees of constitutional poisoning. 

Constitutional or Septic Diphtheria. 

In the form of diphtheria now under consideration — namely, 
the severe form of pharyngeal diphtheria with or without the 
complications just referred to — constitutional poisoning in a 
greater or less degree is invariably present, and, in the absence 
of laryngeal diphtheria, is the chief source of danger. 

Among the earliest symptoms of this condition is cachectic 
pallor, the flush of fever being gradually replaced by an ashen 
or sallow tinge. The eye loses its brightness and the expres- 
sion of the countenance becomes dull and apathetic. There is 
often marked drowsiness. 

The impoverished and poisonous blood-condition reacts 
upon the local inflammation itself. It becomes less acute and 



76 diphtheria; its nature and treatment. 

is attended with less pain. If it continues to extend it does 
so more slowly and insidiously. The pseudo-membrane loses 
its smoothness and whiteness and becomes sodden in appear- 
ance and of a dingy gray, or is dark-colored from capillary 
haemorrhages beneath and around it. The mucous membrane 
around its margin becomes paler or more livid, and is flaccid 
or cedematous. The secretions are ichorous or sanious, and 
very foetid. It is not strange that the symptoms in bad cases 
should have impressed the earlier observers with the belief 
that the process they beheld was one of gangrenous dis- 
organization. 

It is important to remark, however, that grave and fatal 
poisoning may take place in diphtheria without any such 
striking evidences of putrefactive changes in the throat. The 
system may be rapidly infected from a limited diphtheritic 
area in the nasal passages, or from beneath a small and ap- 
parently trivial membranous patch in the throat, if that patch 
penetrates the mucous membrane and its under surface is in 
relation with absorbent vessels, though itself may remain un- 
changed. The view presented by some authorities, that the 
occurrence of septic poisoning in diphtheria depends upon 
putrefactive decomposition of diphtheritic membrane, is a 
dangerous error. The pseudo-membrane is rather a covering 
beneath which the septic processes which are peculiar to the 
disease may go on undisturbed and their products may ac- 
cumulate for absorption and dissemination. The more ad- 
vanced these processes are, however, and the more abundant 
their products, the greater is, of course, the liability to such 
dissemination. 

All the symptoms now manifest a progressive tendency to 
asthenia. The fever usually gradually abates. The temper- 
ature, as a rule, declines to a moderate elevation above the 
normal, or sometimes even falls to 97° Qr 96|° F., though in 
exceptional cases lryperpyrexia is marked and persistent. The 
pulse becomes weaker and is often irregular. It is easily dis- 



SYMPTOMS. 77 

turbed by any slight exertion or excitement. Digestion is 
feeble. There is indifference and often aversion to food and 
drink, and if they are forced upon the patient nausea and 
vomiting result. 

In this form of diphtheria there is almost always albumi- 
nuria, and frequently grave implication of the kidneys. These 
will be separately considered. 

Delirium sometimes occurs, but is infrequent. 

When this form of the disease terminates fatally it is 
usually in the course of the second week — that is, from the 
eighth to the fourteenth day. Death most frequently follows 
a gradual failure of the vital forces caused by the progressive 
impoverishment and poisoning of the blood, or, in other words, 
results from exhaustion and asthenia. The most notable pre- 
ceding symptom is usually the progressive weakness of the 
circulation as manifested in the pulse and the heart-sounds, 
pallor, cold clammy perspirations, coldness of the extremities, 
etc. Sometimes there is a rapid development of the signs of 
pulmonary oedema. In rare instances there are symptoms of 
grave cerebral implication. Quite often death occurs sud- 
denly and more or less unexpectedly by heart-failure after 
some slight excitement or exertion — in some instances after 
merely sitting up in bed — as a result of cardiac paralysis or 
the weakening of the heart by myocardial degeneration. 
Death by this mode takes place not merely during the contin- 
uance of the diphtheritic affection, but in some instances 
weeks after its cessation, and when good progress has been 
supposed to have been made in recovering from its effects. 

When recovery takes place it is usually slow and gradual 
in proportion to the degree of hsemic impoverishment and dis- 
organization and of tissue degeneration. The pseudo-mem- 
brane and the nasal discharge rarely disappear before the 
tenth or twelfth day of the disease. Even before that event 
there is in some cases a mitigation in the constitutional symp- 
toms. In other cases they continue unabated until it occurs 



78 diphtheria; its nature and treatment. 

and then improve with striking- rapidity, showing- their direct 
dependence on the causes just referred to. 

Sometimes after a few hours or a day or two of such im- 
provement there is a return of febrile symptoms, and the 
pseudo-membrane which has nearly or quite disappeared is 
replaced by a new formation accompanied with a renewal or 
intensification of the toxaemia, and causing- another period of 
anxiety and clang-er lasting- from five to ten days, the second 
forma fcion of membrane being- seldom quite as deep or persist- 
ent as its predecessor. In rare cases, when the patient has 
survived this relapse, it is followed by a second of shorter con- 
tinuance, so that the whole duration of membranous disease 
is from three to four weeks. 

In occasional instances the membranous formation is white, 
not very toug-h nor very deep nor very thick, but evidently 
consists of a transformation of the superficial epithelium, or, in 
other words, is of the variety described as " superficial diph- 
theria/' It is closely adherent to the mucous membrane and 
never exfoliates in larg-e pieces. It is often located on the 
anterior side of the soft palate, or around the uvula, or on the 
posterior side of the soft palate, or less frequently on the pos- 
terior wall of the pharynx. Without ever completely disap- 
pearing- this membranous affection sometimes diminishes and 
sometimes extends, with only moderate inflammation and 
fever, but with marked pallor, cachexia and constitutional de- 
pression, persisting- altog-ether from two to four weeks. I 
have seen several such cases in children and two in adults, 
one of whom was seventy years of age. In the last mentioned 
case the temperature varied between 96f ° and 98° F. for nine 
days, being- usually below 97^°; the whole duration of mem- 
branous disease being* four weeks. All these cases termi- 
nated favorably. 

In many cases a prolong-ed and critical period of weakness 
follows the final disappearance of the membranous affection. 
There may be relaxation and catarrh of the upper air-pas- 



SYMPTOMS. 79 

sages ; albumin may persist in the urine for weeks or even 
months, and the heart's action may be feeble and irregular. 

In many other cases, including* some very severe ones, the 
restoration of the patient to complete health and strength is 
surprisingly rapid, all traces of the illness being often oblit- 
erated in the course of a few weeks. 

The symptoms attending convalescence, whether it be rapid 
or slow, and whether it follow a mild or a grave form of the 
disease, are often complicated by the occurrence of paralysis. 

Malignant Diphtheria. 

The term malignant is by some applied indiscriminately 
to all the graver forms of diphtheria in which there are marked 
evidences of constitutional poisoning, but may more conven- 
iently be reserved to designate in diphtheria, as in scarlatina, 
that class of cases which are characterized by exceptional 
earliness and intensity in the systemic poisoning and by such 
rapidity in the course of the disease that the distinctive features 
of its several stages are confused together and unrecogniz- 
able. For this reason they often seem mysterious and inex- 
plicable by the laws which apply to the ordinary forms of the 
malady. 

There are two kinds of malignant diphtheria, the violent 
and the insidious. The former differs from a form of severe 
diphtheria which has already been described, only as the tor- 
nado differs from the ordinary storm. A brief period of rigors, 
vomiting or convulsions is accompanied or succeeded by a 
rapid development of intense and extensive inflammation in 
the throat and the nasal passages, extreme adenitis and a high 
fever, the temperature reaching 105°, 106° or 107° F., and the 
pulse being so rapid that it can hardly be counted. Deep, thick, 
gray, false membrane soon overspreads the whole pharyn- 
geal region, the vault of the palate and sometimes the dorsum 
of the tongue, and obstructs the nasal passages. There is dis- 
charge from the nostrils and marked foot or. Sometimes gan- 



80 diphtheria; its nature and treatment. 

grenous complications occurs. In other cases the diphtheritic 
membrane in the throat is not so extensive, but there is a 
general purplish redness with cedematous swelling" which re- 
sembles phlegmonous erysipelas. 

There is almost from the first an expression of dullness 
and apathy, which in some cases soon deepens into delirium 
or coma. In some cases the fever continues high until the 
fatal termination, which may take place on the third or fourth 
day. In other cases it partially subsides, and the adynamic 
S3^mptoms of septic poisoning and hasmic disorganization al- 
ready described predominate. Haemorrhages occur from the 
nasal or other mucous surfaces, and- petechias appear on the 
skin. Symptoms of grave renal or cerebral implication ap- 
pear. Death takes place on the third to the seventh day. 

The insidious form of malignant diphtheria begins with 
only a moderate degree of febrile disturbance, and the mem- 
branous affection in the throat is of limited extent. There is 
nasal diphtheria, but this may be limited to the post-nasal 
region, where it may be undetected. Marked pallor, depres- 
sion and somnolence almost from the first indicate an over- 
whelming constitutional poisoning, from the effects of which 
and with the symptoms already described, the patient rapidly 
sinks, and dies from the third to the seventh day of the disease. 

Malignant diphtheria is, happily, in proportion to the whole 
number of cases of the disease, only exceptional. It occurs 
with especial frequency in some epidemics, and in the earlier 
rather than the later part of their course. Yet sporadic 
cases are now and then malignant. There seems to be in 
some individuals and in some families a predisposition to 
grave forms of diphtheria, as is also the case in regard to 
scarlatina. From the circumstances under which such forms 
of the disease occur, and from facts which are elsewhere 
stated, it is probable that they are the result of two factors — 
first, a contagium of especial virulence, and, second, the early 
penetration into the body of septic organisms. 



SYMPTOMS. 81 

Previously impaired vitality or blood contamination from 
insanitary conditions may not infrequently enter into the ex- 
planation of the more " insidious " cases. . 

Gangrene. 

Though the belief of the older writers that diphtheria is a 
gangrenous affection has been found to be erroneous, the two 
morbid conditions being distinct, yet gangrene does occur in a 
small proportion of cases in connection with, and as a result 
of, diphtheria. 

Gangrene occurs in those forms of diphtheria in which the 
inflammation is intense and the infiltration is deep. A greater 
or less portion of tissue dies and sloughs away. Yet it does not 
occur in all such cases, nor, as a rule, in the worst ones. In 
many fatal cases in which these conditions are most marked 
there is no gangrene, and, per contra, some cases recover in 
which there has been considerable destruction of tissue by gan- 
grene, the diphtheritic affection not having been especially for- 
midable. It is also to be noted that gangrene in diphtheria does 
not depend on the amount of the constitutional poisoning, for in 
many of the most malignant toxic cases gangrene is absent, 
and I have seen it in several cases in which blood-poisoning 
was not especially pronounced. 

Gangrene may accompany diphtheria in almost any situa- 
tion, but does so most frequently on the soft palate. The 
entire uvula or one of the palatal arches sometimes sloughs 
away and occasionally the soft palate is perforated. Gan- 
grene does occur on the tonsils, though rarely. It should by 
no means be associated with the gaping cavities sometimes 
seen in them after the pseudo-diphtheria which accompanies 
follicular tonsillitis, in which there is usually no actual loss of 
tissue. I have seen gangrene in diphtheritic patches on the 
inside of the cheeks. It sometimes occurs on the lip and 
in cutaneous and vulvar diphtheria, etc. 

Destructive as the gangrenous process in diphtheria some- 



82 diphtheria; its nature and treatment. 

times appears, yet as a rule the actual amount of deformity 
which remains after cicatrization is comparatively slight. 

Laryngeal Diphtheria. 

Laryngeal diphtheria, or diphtheritic croup, is in the ma- 
jority of cases the result of the extension of the disease down- 
ward from the pharynx; but in not a few cases it occurs first 
in the larynx and later makes its appearance in the pharynx, 
while in some instances it never extends above the larynx. 
Extension from the pharynx most frequently occurs within the 
first four or five days of the disease, being comparatively rare 
at a later stage. Its presence is then made known by the 
gradual addition of the symptoms of croup to those of the 
faucial affection. 

' The amount of febrile and nervous disturbance that attends 
the onset of primary laryngeal diphtheria is very various, be- 
ing sometimes considerable and in other cases remarkably 
slight. The first distinctive symptoms of its occurrence are 
those of laryngeal inflammation and irritation. There is 
usually a characteristic cough, which may be harsh, dry and 
somewhat shrill or hoarse and muffled. It is usually, though 
not always attended with pain. The voice is altered, being 
roughened and husky or weakened and indistinct, and speak- 
ing and crying are often painful. The respiration is not usu- 
ally at first affected. As the disease progresses the symptoms 
of laryngeal stenosis become more marked. The cough is 
hoarse and metallic, the voice raucous or whispering, and the 
respiration is more and more obstructed in both acts, inspira- 
tion especially being labored, prolonged and stridulous, and 
accompanied with depression above the sternum and clavicles, 
in the intercostal spaces and over the diaphragm. 

In the earlier stage of the affection these symptoms are 
usually intermittent or variable, being increased by the pres- 
ence of mucus in the larynx, or excited by crying and strug- 
gling, there being a tendency in this, as in other forms of 



SYMPTOMS. 83 

laryngitis, to more or less spasmodic tightening- from time to 
time. As the disease progresses and stenosis increases they 
become more constant. 

The subsequent course of the malady varies greatly in 
different cases. In some, which are unfortunately hut a small 
proportion of all, the croupous exudation in the larynx is only 
a thin pellicle, the accompanying tumefaction is not very great 
and the spasmodic closures not very severe or persistent. The 
dyspnoea and other symptoms of the affection may persist for 
a period varying from four or five to eight or ten days, vary- 
ing in intensity but never entirely intermitting on the one 
hand, nor, on the other, becoming so severe as to entirely pre- 
vent respiration. At length the membrane exfoliates, the 
inflammation subsides, and. the symptoms of obstruction dis- 
appear, either quite suddenly or gradually. 

In the large majority of cases, however, the affection has a 
malign, and often a treacherous character, which fully justifies 
the dread in which it is universally held. Not infrequently, 
after pursuing for some days a mild course such as has just 
been described, or even apparently abating in severity, from 
some slight exposure to cold, or often without any evident 
explanation, there is an aggravation of all the symptoms so 
rapid that almost before its seriousness is realized death occurs 
from asphyxia. 

In other cases the course of the affection is from the first 
steadily from bad to worse. The rapidity may be so great 
that fatal laryngeal occlusion shall take place within twenty- 
four hours from the commencement of the croupal symptoms 
— a possibility most important to be realized. It occurs still 
more frequently on the second day and the succeeding ones 
up to the fifth, and then with diminishing frequency up to the 
tenth or twelfth, or in rare cases even a later one. 

As this event approaches the gravity of the symptoms be- 
comes painfully apparent to the most inexperienced beholder. 
The cough is muffled and abortive. The voice is suppressed 



84 diphtheria; its nature and treatment. 

to a hoarse whisper. The breathing" is stridulous and labored 
in both acts, inspiration being- especially prolonged, and the 
accompanying depressions in the supra-clavicular and other 
spaces being very marked. The patient, if a child, either sits 
up constantly or starts up frequently, turning appealingly to 
his parents or nurse for relief, or throws himself violently about 
in his frantic efforts to get breath, his countenance expressing 
alarm and distress, the hue cyanotic. 

These symptoms are often accompanied with the evidences 
of blood-poisoning which have previously been described. This 
is likely to be the case in proportion to the time the disease 
has continued, and to the amount of the accompanying pha- 
ryngeal and nasal affection. 

Death in laryngeal diphtheria results from asphyxia caused 
by the occlusion of the laryngeal aperture by pseudo-membrane, 
by tumefaction of the mucous membrane, by spasm, by oedema 
of the glottis, or by a flap of partially detached false mem- 
brane acting as a valve, or from the effects of the extension of 
the membranous affection downward through the bronchial 
tubes. 

The character and course of the symptoms vary very much 
according to the age of the patient, the tendency to laryngeal 
stenosis being greater the younger he is, from the fact that 
the laryngeal aperture is both absolutely and relatively 
smaller in children than in adults, and in young children than 
in older ones. 

Although the mode of termination just sketched is unfortu- 
nately that of the great majority of cases of laryngeal diph- 
theria in which operative measures are not employed, yet there 
are exceptional recoveries which prove that no case is abso- 
lutely hopeless unless it is made so by complications. Some^ 
times when death by asphyxia seems imminent the obstructing 
false membrane is opportunely coughed up. I have known of 
several striking instances in which life has been thus saved 
almost at the last moment. 



symptoms. 85 

Tracheal and Bronchial Diphtheria. 

Diphtheria of the trachea and the bronchial tubes is usually 
the result of the extension downward of the disease from the 
larynx, though in some cases it occurs without any implication 
of the larynx in connection with pharyngeal or nasal diph- 
theria. It is a very common accompaniment of laryngeal 
diphtheria, and is the most frequent cause of the failure of 
tracheotomy or intubation to avert a fatal issue. In some 
instances it extends through the bronchial tubes to their ulti- 
mate ramifications and into the air-cells themselves. 

The pseudo-membrane in these localities is of the kind de- 
scribed as " croupous," lying loosely upon the mucous mem- 
brane. It is of various degrees of thickness and is usually of 
not very firm consistency. 

Among the most usual results of tracheo-bronchial diph- 
theria are broncho-pneumonia and pulmonary collapse. Its 
symptoms are those of bronchitis with marked dyspnoea and 
cyanosis, which are frequently complicated by those of the 
affections just mentioned. Owing to the dyspnoea caused by 
the laryngeal affection, the physical signs of tracheal and 
bronchial diphtheria are obscure and indistinct. Its presence 
is in rare cases made a certainty during life by the coughing 
up of membranous casts of the bronchial tubes. 

Diphtheria of the Ear. 

Diphtheria of the Eustachian tubes, the tympanum and the 
external ear is usually the result of the extension of the disease 
to those parts from the pharynx. The symptoms are those of 
ordinary otitis media, with the addition of diphtheritic exuda- 
tion. This lines the Eustachian tubes, follows the suppura- 
tive inflammation through the cava tympani, and after 
perforation of the drum overspreads the wall of the meatus 
externa and sometimes the adjacent cutaneous surfaces. In 



86 diphtheria; its nature and treatment. 

the middle ear diphtheritic otitis is usually very destructive, 
hearing- being" permanently impaired or destroyed. 

Diphtheritic otitis media rarely, if ever, occurs in the course 
of primary diphtheria. It has been observed in the diphtheria 
which follows small-pox and some other diseases, hut in the 
great majority of all cases is a complication or sequela of 
scarlatina. So uniform, according- to my experience, is this 
relation of the two diseases, that I long- ago learned to regard 
the occurrence of otitis in connection with diphtheria as strong- 
presumptive evidence that the diphtheria was of scarlatinal 
origin. In a number of such cases in which that origin had 
not been recognized, I have learned, on carefully tracing back 
their early history, that there had been characteristic symp- 
toms of scarlatina, though so slight and so transient as to 
have been disregarded. Several of these cases have been seen 
by me in consultation with other physicians, who have been 
convinced of their scarlatinal origin by a careful consideration 
of evidences which had previously escaped their notice or been 
regarded as inconclusive. 

Diphtheria of the meatus externa not resulting from otitis 
media has been observed in rare cases. It has usually, at 
least, supervened upon a catarrhal affection of the part 

Diphtheria of the Eye. 

Diphtheritic conjunctivitis may occur as a primary affec- 
tion or may supervene upon purulent conjunctivitis. It is also 
in rare cases consecutive to nasal diphtheria by extension 
through the lachrymal duct. 

It varies very much in intensity, being sometimes a com- 
paratively mild and limited affection, but more often very 
severe and destructive to the eye. 

It begins more usually upon the palpebral conjunctiva. 
The diphtheritic exudation is sometimes in thin patches which 
cannot easily be detached ; in other cases it is thick, gray and 
coherent, and can be stripped off in large pieces. 



SYMPTOMS. 87 

When the affection is primary and severe it is attended 
with great swelling, heat, pain and sensitiveness in the eye- 
lids. The conjunctiva, at first red and vascular, is later dry, 
smooth and of a grayish yellow. This is the result of the 
dense infiltration of its substance, which compresses the blood- 
vessels and checks the circulation. Numerous extravasations 
of blood may be seen upon it. This dense infiltration in the 
chemosed ocular conjunctiva strangulates the blood-vess3ls 
which supply the cornea and thus greatly interferes with its 
nutrition; hence the cornea is very liable to undergo ulcera- 
tion, suppuration and perforation. The earlier in the course 
of the affection this ulceration occurs the more extensive and 
destructive it is likely to be. 

After a few days the conjunctiva becomes less tense and 
hard and more moist and vascular, and there is a copious pur- 
ulent discharge. The membranous exudations become softened 
and loosened, and finally are detached, but relapses are very 
liable to occur. 

Diphtheritic conjunctivitis may be limited to one eye, but in 
most cases affects both. Its discharge is exceedingly contagi- 
ous. It is not a very common affection, but it sometimes 
occurs epidemically. It is much less common in this country 
than in some parts of Europe. Dr. W. O. Moore informs me 
that in the records of the New York Eye and Ear Infirmary 
for fifteen years but two cases of ocular diphtheria appear. 

Diphtheria of the (Esophagus, Stomach and Intestines. 

Diphtheria of the (Esophagus is very rare and is usually 
secondary to other diseases. 

The symptoms of oesophageal diphtheria are not distinctive. 
They would of course be expected to be pain, dysphagia, chok- 
ing sensations, vomiting, reflex cough, etc. Yet these symp- 
toms have been absent in cases in which the autopsy revealed 
the existence of the affection, and have been present in many 
cases in which no such condition existed. In a majority of the 



88 DIPHTHERIA; ITS NATURE AND TREATMENT. 

cases in which it has occurred its presence has been unsus- 
pected until discovered at the autopsy. Hence its diagnosis is 
in a large proportion of cases difficult or impossible. This 
obscurity is characteristic of oesophageal affections in general. 
Of forty -four cases reported by Steffen, 1 including diphtheria, 
catarrhal inflammation, ulceration, gangrene, etc., as shown 
at the autopsy, the diagnosis had been made in only three. 

Cicatricial stricture of the oesophagus has in a few cases 
occurred as a sequel of diphtheritic ulceration. 

Diphtheria of the stomach is also a rare affection, and its 
symptoms are necessarily obscure. It has been found in 
some autopsies affecting either limited portions of the gastric 
mucous membrane or, in a few instances, nearly its entire sur- 
face. 

Diphtheritic inflammation of the mucous membrane of the 
small and the large intestine has also occurred. Its existence 
has in a few instances been made known during life by the 
passing of membranous casts of the bowel, but in most cases 
has only been revealed at the autopsy. 

Diphtheria of the anus has been observed in quite a number 
of instances, sometimes extending upward into the rectum or 
over the adjoining skin. 

Diphtheria of the Genito-Urinary Organs. 

Diphtheria has occurred in the urinary bladder in chronic 
cystitis and in connection with stone in the bladder, and also 
following various surgical operations on that organ. It has 
also invaded the uterus as a puerperal complication and after 
surgical operations. It sometimes occurs in the vagina under 
the same circumstances. 

Diphtheria of the vulva is a not infrequent form of the dis- 
ease. It usually occurs daring the endemic or epidemic prev- 
alence of the pharyngeal affection, sometimes as a complica- 

1 Quoted by Dr. H. D. Fry, in a Valuable and exhaustive article on 
this subject, Am. Jour. Med. Sc, October, 1885. 



SYMPTOMS. »y 

tion in the same patient, and sometimes in others who have 
been exposed to the contagion of the disease. There is usually 
some accompanying- inguinal adenitis, but this may be slight 
or absent. The affection sometimes extends over the adjoin- 
ing skin, and in rare cases involves both the vulva and the 
anus with the region between them. 

Diphtheria of the Skin and of Wounds. 

That diphtheria shall affect the skin it is necessary that 
the epidermis be first removed or penetrated. Thus in former 
times it often invaded blistered surfaces, leech-bites and ven- 
esection wounds. Its frequent occurrence on the skin of the 
upper lip from the excoriating effect of the acrid discharge 
from the nostrils in nasal diphtheria has been referred to. 
Diphtheria having- once gained a foothold on an abraded surr 
face, spreads over the contiguous sound skin, making its way 
along- the corion and displacing the epidermis by a process of 
destructive inflammation. It usually extends downward. 

Diphtheria also invades the surface of wounds where no 
true skin remains. This is especially liable to occur in hospi- 
tals in the presence of similar conditions to those which pro- 
duce hospital g-angrene, with which it is often complicated. 
Diphtheria of wounds is characterized by the formation upon 
them of a whitish, grayish or greenish pellicle of varying 
thickness. The purulent discharge is dried up and is replaced 
by an acrid, ichorous fluid. The edges of the wound are thick- 
ened and cedematous, and sometimes surrounded by an erysip- 
elatous inflammation. The affection may be superficial or 
deep, with a tendency to become phagedenic or gangrenous. 
Septic absorption is liable to occur in this as in other forms of 
the disease. 

Albuminuria and Nephritis. 
If the urine of patients suffering- with diphtheria be ex- 
amined daily it will, in about half of all cases, be found at some 
time in the course of the affection to contain albumin. 



90 diphtheria; its nature and treatment. 

According- to M. Sanne, 1 out of 410 cases in which albumin 
was sought it was found in 224. According to Dr. J. Lewis 
Smith, 2 of sixty-two cases examined twenty-four were attended 
with albuminuria, and thirty-eight were exempt. 

Albuminuria makes its first appearance in rare cases of 
diphtheria as early as the first or second day, then with in- 
creasing frequency until the eighth or ninth, then with dimin- 
ishing frequency until the eleventh or twelfth, and in rare 
cases subsequently to that period. It begins, therefore, in 
the great majority of cases during the period at which there 
is the greatest intensity of the constitutional disease. In view 
of this circumstance it cannot be doubted that toxaemia is its 
principal cause in most serious cases. This conclusion is con- 
firmed by the fact, established by many careful observers, that 
it is usually in those cases of diphtheria in which other evi- 
dences of constitutional poisoning are most marked that 
albuminuria in its more serious forms is seen. 

It is, however, important to remember that there are also 
various other known and unknown causes of albuminuria which 
may be present in diphtheria, and which may be wholly or 
partially responsible for its occurrence, especially in its slighter 
manifestations. Albuminuria occurs not only in the course 
of infectious diseases but also in connection with various other 
febrile and catarrhal affections, including non-diphtheritic an- 
ginas. It occurs not infrequently in persons apparently in 
perfect health. 3 Among its leading causes is exposure to cold, 
a circumstance which often precedes an attack of diphtheria. 

It is evident, therefore, that the idea, advanced by some 
authors, that the presence or absence of albuminuria may be 
a diagnostic criterion between diphtheritic and pseudo-diph- 
theritic affections is erroneous. It is equally evident that 
the argument which has often been urged, that because albu- 
minuria sometimes appears at an early stage of diphtheria, 

1 Op. cit. p. 129. 2 " Diseases of Children," 1886, p. 312. 

3 Flint, "Practice of Medicine," 1881, p. 809. 



SYMPTOMS. 91 

therefore the disease is a primarily constitutional one, is based 
on a misconception of the facts. 

In a considerable proportion of cases in which albuminuria 
is due to extrinsic causes, or even to a slight degree of diph- 
theritic poisoning, it is small in amount, transient, accom- 
panied with few or no renal casts and with no symptoms 
of ursemic poisoning, and is of no serious prognostic sig- 
nificance. 

But many cases remain which result from the constitu- 
tional infection, are in direct proportion to the degree of that 
infection, are accompanied with more or less profound urasmia, 
and both from the mischief they indicate and the additional 
mischief they cause are of grave significance. 

The urine presents various appearances; it is usually nearly 
normal in color and transparency, but frequently becomes 
cloudy on cooling from the precipitation of urates. It is often 
rather scanty and of increased specific gravity, especially in 
the earlier stage. In rare cases it is dark-colored or smoky 
from the presence of blood. The amount of albumin varies, 
but in severe cases it is usually in considerable quantity. In 
such cases there are also present granular, epithelial and 
hyaline casts. 

Of 233 cases of diphtheria with albuminuria, according to 
M. Sanne, 142 died, and 91 recovered; but of 160 cases without 
albuminuria, 97 recovered and 63 died. Of 22 cases without 
albuminuria, according to Cadet de Gassicourt, 1 12 recovered 
and 10 died. In 29 cases in which there was only a trace of 
albumin, 12 recovered and 17 died. In 19 cases in which the- 
amount of albumin was considerable, 8 recovered and 11 died. 
In 16 cases in which the amount of albumin was very large, 3 
recovered and 13 died. 

While these figures roughly confirm the views expressed 
above as to the unfavorable significance of albuminuria, yet 
they give no precise information on that point, since they make 
1 Rev. Mens, des Mai. de l'Enf., November, 1884. 



92 diphtheria; its nature and treatment. 

no distinction between deaths from laryngeal asphyxia and 
from the effects of constitutional poisoning-. Much more in- 
structive are the following' figures, given by Dr. J. Lewis 
Smith : 1 Of 18 cases of diphtheria without membranous lar- 
yngitis and with albuminuria, 13 died and 5 recovered; while of 
31 such cases without albuminuria, 4 died and 27 recovered. 
"In nearly all the specimens which contained albumin — all 
but three or four — casts, usually granular, but now and then 
hyaline, and sometimes both kinds in the same specimens, 
were observed. In those cases of albuminuria which recov- 
ered, there were comparatively few casts or none." 

The assertion of Trousseau that albuminuria in diphtheria 
"has only a limited significance in relation to prognosis and 
treatment," can therefore be accepted only with important 
qualifications. 

The duration of albuminuria in diphtheria varies from one 
or two days to one or two weeks, or in rare cases a longer 
period. It very rarely becomes chronic. It is sometimes re- 
markably variable or intermittent. I have in some instances 
seen its variations closely correspond to those of the local dis- 
ease, the albumin repeatedly diminishing or disappearing with 
the cessation of nasal discharges or the exfoliation of mem- 
branes, and again becoming abundant on the occurrence of re- 
lapses. 

Albuminuria in diphtheria is in only a very small propor- 
tion of cases attended with any marked degree of oedema. 
Trousseau estimates this proportion in his own experience at 
one case in twenty. It is especially liable to occur in those 
cases in which blood corpuscles are present in the urine. 

Certain differences between the albuminuria of diphtheria 
and that of scarlatina are noteworthy. The former usually 
begins during the active continuance of the disease and before 
its tenth day, the latter at a later period and as a sequela. 
The former is rarely accompanied with oedema ; it is a fre- 

1 Loc. cit. 



SYMPTOMS. 93 

quent attendant of the latter. The former in a smaller pro- 
portion of cases denotes important disease of the kidneys, but 
Avhen this occurs it is of more serious prognostic import. 
The former very rarely becomes chronic ; the latter not very 
infrequently does so. 

The Lungs. 

The pulmonary conditions which are liable to occur in con- 
nection with laryngeal, tracheal and bronchial diphtheria have 
already been referred to. Their symptoms are the same as 
when they result from other causes, but their physical signs 
are often so obscured by the dyspnoea caused by the laryn- 
geal stenosis that their diagnosis is difficult or impos- 
sible. The occurrence of an increase of febrile symptoms, 
with excessive rapidity of respiration and with or without 
cough in the course of diphtheritic croup, either before or after 
tracheotomy or intubation, should suggest the probability of 
an inflammatory pulmonary complication having' occurred 
and lead to a careful examination of the chest. Broncho- 
pneumonia usually results from the impeded respiration caused 
by laryngeal stenosis or from the extension downward of fibri- 
nous or catarrhal bronchitis. It is maintained by some and 
denied by others that pneumonia may be caused by the draw- 
ing of blood into the lungs during tracheotomy. 

Bronchitis, broncho-pneumonia, lobar pneumonia, pulmo- 
nary congestion, pulmonary oedema and pleurisy may occur in 
non-laryngeal diphtheria attended with septic poisoning, as in 
other adynamic toxgemic diseases. 

The Heart. 

The symptoms resulting from the functional disturbances 
or organic lesions of the heart in diphtheria, have been referred 
to in describing the various stages and forms of the disease. 
These symptoms may be due (1) to cardiac paralysis; (2) my- 
ocardial degeneration and consequent weakening and dilata- 



94 DIPHTHERIA* ITS NATURE AND TREATMENT. 

tion of the heart-walls; (3) endocarditis with fibrinous deposits 
upon the valves of the heart; (4) gradual exhaustion of the 
vital forces; (5) the formation of thrombi in the cavities of 
the heart (ante-mortem heart-clot). Frequently several of 
these causes act simultaneously, especially in the later stage 
of fatal cases. 

The occurrence of organic lesions may be recognized by 
the usual physical signs of these conditions. The symptoms 
of heart-failure may be gradual and progressive or sudden 
and unexpected, and may appear early in the disease or at 
a late period and after apparent convalescence. 

Eruptions. 

Eruptions have been described by various observers of 
diphtheria as having occurred in a portion of the cases of the 
disease in some epidemics. The predominant form has resem- 
bled the exanthem of scarlatina, but other forms have been, 
similar to that of measles or that of roseola or to urticaria, 
and still another has been vesicular. These eruptions are 
attended with no special symptoms and are not followed by 
desquamation. They have not usually been observed to 
have any definite significance as to the gravity of the disease 
or its prognosis. In the observation of many hundreds of 
cases of diphtheria I have never seen an accompanying erup- 
tion that was not evidently a purely accidental complication. 
In the observations of M. Sanne 1 one case in fifty was attended 
with an eruption. The supposition of some writers, that these 
eruptions hold the same relation to diphtheria that those oc- 
curring in typhus or typhoid fever hold to those diseases, 
seems to be negatived b} T the extreme rarity of their occur- 
rence and by their lack of uniformity in type. It is reasonable 
to suppose that some of the recorded cases may have been in 
reality cases of scarlatina, in which the eruption was so slight 
and so transient and the accompanying symptoms so incom- 

1 Op. cit. p. 138. 



SYMPTOMS. 



95 






plete that the real nature of the affection was not recognized. 
The majority are doubtless merely cases of erythema "sim- 
plex " or " fugax," occasioned by the fever under certain indi- 
vidual or local or epidemic conditions. 

Purpura haemorrhagica has been already referred to as not 
infrequently occurring- in the course of malignant and grave 
forms of septic diphtheria. 



CHAPTER V. 

THE PRIMARY NATURE OF DIPHTHERIA. 

Is diphtheria primarily a local or a constitutional disease ? 

The importance of this question arises from the fact that 
its answer must be fundamental to any rational theory of 
treatment. 

In 1876, 1 stated * that the result of my clinical observa- 
tions, which had included the early stages of many cases, 
had been to make me a convert to the minority, who believe 
that the source of the constitutional disease is, in the great 
majority of cases at least, to be found in the local affection. 

I have since been confirmed in that view by many subse- 
quent clinical observations, and also by important corrobora- 
tive facts which have been elicited in pathological and bac- 
teriological research by investigators in this and in other 
countries, and which have been stated in the chapter on 
etiology. 

I shall now present some of the clinical facts upon which 
this belief is based, and shall consider some of the statements 
and arguments which have been advanced in opposition to it. 

First. — Diphtheria occurs in the great majority of cases 
upon the mucous membrane of the fauces, the larynx, the 
nasal passages and the mouth, or, in other words, the outer 
avenues of entrance of inspired air and of food and drink, and 
with the greatest relative frequency in exactly those positions 
where particles of matter introduced by them would most 

1 " Diphtheria and its Treatment, with Statistics of one hundred and 
seventy-nine Cases." Transactions of the New York Academy of Medi- 
cine, 1876, p. 286. 



THE PRIMARY NATURE OF DIPHTHERIA. 97 

naturally be deposited, which fact suggests a probability 
tbat the disease is directly and locally caused by such contact 
or implantation. This probability is greatly strengthened by 
the fact that it occurs in sharply limited, irregular and non- 
symmetrical areas, which is not the case with the throat- 
inflammations resulting from blood-diseases, such as scarla- 
tina and small-pox. This probability is still further strength- 
ened by the fact that when it attacks the skin, which has a 
more efficient protection in its epidermis, it affects only such 
portions of it as have been deprived by wounds and abrasions 
of that protection. These circumstances taken together con- 
stitute a very strong a priori argument. Although they 
have not escaped previous notice I have never seen a satisfac- 
tory explanation of them in accordance with the opposite 
theory of the disease. 

It is argued, 1 per contra, " If diphtheria were a local dis- 
ease at first, commencing in the throat and then becoming 
constitutional by absorption, what organs would be more ex- 
posed to the reception of its poison than the digestive pas- 
sages, which are in habitual contact with the debris of the 
false membranes swallowed with the saliva and with food,, 
when they are not constantly bathed in an ichorous fetid 
liquid which proceeds from the fauces ? In spite of these con- 
ditions, so favorabLe to the development of false membranes, 
their presence in the oesophagus, the stomach and the intes- 
tine is exceptional." This argument has apparently great 
force, for while it may readily be answered, in so far as the 
stomach and intestines are concerned, that the gastric juice 
has probably the property of destroying the infectiousness of 
the materials referred to, some other explanation is required 
for the exemption of the oesophagus, which is most directly 
exposed to them and is not thus defended. That explanation 
may be found in the protection which it receives from the es- 
pecially dense epithelium which covers its mucous membrane. 
'Sanne, Op. cit., p. 362. 



98 diphtheria; its nature and treatment. 

Zenker and von Ziemssen 1 remark : " The sharply defined 
anatomical and histological differences between the mucous 
membrane of this organ and the parts with which it connects 
at either end are usually accompanied with an equally well- 
defined limitation of pathological processes, particularly the 
inflammatory." Another and more comprehensive explana- 
tion of the exemption of the regions referred to from diphthe- 
ritic inflammation has been referred to in the chapter on 
etiology, in the fact that free oxygen is under ordinary con- 
ditions absent in them, and that the bacterium of diphtheria 
is probably aerobious — either explanation being in accordance 
with the theory of the local character of the disease. 

Second. — The constitutional disease, as I have more fully 
stated in the chapter on symptoms, is, in the order of time, 
not antecedent to but consequent upon the local affection. 
Fever, rigors, or even convulsions may indeed be the first 
symptom to attract attention and do precede the formation 
of membrane, but in all cases, if the throat be examined at 
that stage of the disease, inflammation will be found to be 
present. 

A common source of error on this point is that the " symp- 
tomatic " fever and nervous disturbances which are common 
to the onset of many inflammatory affections, including sim- 
ple catarrhal anginas, are strangely confounded with the exi- 
dences of constitutional infection or blood-poisoning, which in 
diphtheria, as is universally agreed, consist of pallor, somno- 
lence, weakness, etc. In most clinical descriptions of diphthe- 
ria, the last-mentioned symptoms are said to usually occur 
at various periods of the disease subsequent to the local in- 
flammation and the formation of membrane. 

Another cause of much error on this point is the fact that 
in some cases in which pseudo-membranous exudation already 
exists there has been no complaint of pain or soreness of the 
throat. The more strictly the physician observes the rule to 

1 " Diseases of the Oesophagus," Ziemssen's Cyclopaedia, vol. viii. 



THE PRIMARY NATURE OF DIPHTHERIA. 99 

examine the throat of every sick child, the fewer will be the 
cases in which he will suppose the constitutional symptoms to 
have preceded the local ones. 

Another source of error is the fact that diphtheria often 
supervenes upon some other disease. A child, for instance* 
has taken cold, from the effects of which he is drooping- and 
feverish for several days. Upon the catarrhal sore-throat 
thus produced diphtheria sets in. The previous symptoms 
are naturally supposed to have been those of the invasion of 
the latter disease, when in fact they were nothing- of the kind. 

Still another source of error, and a very important one, is 
the fact that false membrane often occurs in some concealed 
situation. That situation is most usually the posterior nares. 
I have in a number of instances found an explanation of con- 
stitutional symptoms of diphtheria which were otherwise un- 
accountable, by washing- portions of false membrane from 
that localit3 r by nasal syringing-. Dr. D. Bryson Delavan has 
informed me that he has seen quite a number of instances of 
physicians or nurses who, after attendance upon cases of 
diphtheria, have suffered from the constitutional symptoms of 
the disease, although no membrane has been visible in the 
throat or elsewhere by ordinary modes of inspection; but on 
examining- the posterior nares with the rhinoscopic mirror, 
patches of unmistakable diphtheritic membrane have been 
seen in that situation. In one fatal case with symptoms of 
diphtheritic poisoning- which was reported by me, 1 the only 
false membrane was found post-mortem in the bronchial tubes. 
Such facts furnish an obvious explanation of cases which have 
been adduced in support of the assertion that diphtheria may 
occur without a diphthera. 

To the statements which have just been made are opposed 
contradictory ones by writers of great excellence and author- 
ity. M. Sanne, who argues with earnestness and force in favor 
of the primarily constitutional nature of diphtheria, 2 says, " It 
. 1 New York Medical Record, April 16,1887. 2 Op. cit., p. 363. 



100 diphtheria; its nature and treatment. 

is quite as common, if not more so, to find the diphtheritic 
poisoning" evident from the outset, and it is those cases in 
Avhich it is most intense which begin thus; the false membrane 
is then but an unimportant element." But when we turn 
from that statement, made in the stress of argument, to the 
chapters in which he describes the symptoms of the disease, 
we find the onset of the different forms thus delineated: 
"Benign form. — This commences by a debut like one of the 
non-diphtheritic inflammatory anginas, provided they acquire 
a certain violence." The usual symptoms of the onset of this 
class of affections — fever, rigors, anorexia, lassitude, headache 
— are mentioned (page 118). '''The same day or the next one 
the patient, if he is old enough, complains of a sore throat," 
etc. "Examination of the throat shows from the outset 
(d'abord) a more or less vivid redness of the pharynx." (page 
182). No symptom distinctive of diphtheritic poisoning" is 
mentioned in connection with the onset of this form. — " Infec- 
tious form. — The commencement is the same" (as in the pre- 
vious form), "but at the end of a few days characteristic 
symptoms appear" (page 119). One of these is (page 120) 
that "the complexion, at first bright, becomes pale, livid, 
leaden." (The italics are mine.) The malignant form pre- 
sents two varieties. " In the first " (page 122), " which may be 
called forme foudroyante, the symptomatic complex is the 
same as in the preceding form, and is distinguished from it 
only by the rapidity with which the symptoms succeed" In 
this form the false membranes may be very extensive or very 
slight, but "however limited they may be the neck presents 
an enormous tumefaction" from glandular swelling. What 
description could be more suggestive of toxic absorption from 
a local source? The second variety, the "insidious form, 
leads in the beginning to an expectation of benignity which 
proves cruelly deceptive. The lesions are unimportant, but 
they extend from the throat into the nose " — a situation which 
M. Sanne elsewhere recognizes as especially favorable to toxic 



THE PRIMARY NATURE OF DIPHTHERIA. 101 

absorption. In short, while we find in the admirable general 
descriptions of diphtheria by this author, which may fairly be 
presumed to include its more usual manifestations much which 
is illustrative of constitutional poisoning 1 from a local source, 
we search in vain for distinctive evidences of diphtheritic poi- 
soning* at the initial stage of the disease, unless, indeed, the 
fever and the concomitant nervous disturbances which attend 
the primary inflammation are to be so regarded. 

This view is not without advocates. Since the fever; how- 
ever, behaves in diphtheria precisely as it does in various 
simple catarrhal anginas — that is to say, as a general rule 
begins and ends with the inflammation, and is in direct' propor- 
tion to it — it is most natural to suppose that it is, as in them, 
simply the attendant and the result of the inflammation. Ex- 
ceptionally, it is true, it apparently precedes the latter by a 
little, or is disproportionately high, but this is likewise true in 
ordinary catarrhal anginas, and when it is the case we look 
for the explanation either in some constitutional peculiarity of 
the patient, or in some peculiarity of the inflammation which 
is not evident, or in some undiscovered complicating inflam- 
mation or in some pre-existing and complicating constitutional 
poisoning (malarial, septic, rheumatic, etc.), which explana- 
tions are equally available in diphtheria. 

Third. — The gravity of the general disease varies directly, 
as a general rule, in proportion to the extent and more par- 
ticularly the depth of the local affection. While this propo- 
sition is substantially sustained by the testimony of most 
observers of various pathological views, it is maintained, per 
contra, by some excellent authorities that the correspon- 
dence referred to is not constant, that a grave constitu- 
tional disease may accompany a very slight local affection, 
and that death has resulted from the primary poison of diph- 
theria in cases in which but little membrane or even no mem- 
brane has existed. 

It is answered that such cases are admittedly so rare as to 



102 diphtheria; its nature and treatment. 

be exceptional, and that there is great liability to error re- 
specting- them. To the sources of such possible error already 
referred to in defective observation and in the occurrence of 
diphtheritic membrane in concealed situations, the following 
may be added, all of which have been illustrated in my own 
experience: An apparently insignificant membranous patch 
which penetrates deeply may result in profound toxaemia, while 
an extensive but superficial one may cause scarcely any. A triv- 
ial membranous deposit in'situations favorable to absorption (as 
for instance the nares) may have far greater constitutional re- 
sults than apparently formidable ones in different anatomical 
relations (as the convexity of enlarged tonsils). Again, it is well 
known that epidemics of diphtheria and of scarlatina are fre- 
quently associated, and that this association has been a fruit- 
ful source of confusion. How naturally under such circum- 
stances might a death from malignant scarlatina without 
eruption be erroneously attributed to diphtheria ! Finally, it 
must be admitted that in some cases of diphtheria the 
amount of false membrane is disproportionately slight to the 
septic intoxication; but it does not necessarily follow that 
the latter is the primary fact. It is more reasonable and 
more in accordance with many analogies in surgical and 
puerperal sepsis to suppose that the progress of the dis- 
ease from local to general is in these cases either from some 
special condition or tendency pre-existing in the patient, or 
some extraordinary virulence in the contagium, or perhaps 
from both circumstances concurring, more rapid than in or- 
dinary ones, and that it is complicated by the early penetration 
into the system of septic microbes. 

Fourth. — The employment of proper local antiseptic treat- 
ment does in many cases promptly mitigate or quite dispel 
constitutional symptoms previously existing, or, if early em- 
ployed, prevent, either wholly or in some measure, their occur- 
rence, and its failures to accomplish these objects occur in 
exactly those cases in which from the nature of things it can- 



THE PRIMARY NATURE OF DIPHTHERIA. 103 

not be or in which it is not efficiently employed. The proof of 
these assertions will be presented in the chapter on treatment, 
to which the reader is referred. 

While the foremost place in the treatment of diphtheria is 
conceded to topical measures by many authorities who hold to 
the opposite pathological view of the disease, it is asserted by 
some as an argument in favor of that view (1) that local treat- 
ment does not cut short the disease, and (2) that it does not in 
severe cases prevent the occurrence of constitutional symp- 
toms. Even if the first assertion be true, which question will 
be elsewhere considered, the argument is without force, since 
the same is admittedly true in the case of gonorrhoea and 
some other local affections, which evidently penetrate the liv- 
ing tissues too deeply to be eradicable by disinfectants which 
act only or mainly on their surface. In reference to the second 
assertion it may be said that the limitations to the efficacy of 
local antiseptic treatment in diphtheria, being such as is 
stated above, are in reality, equally with its successes, illus- 
trative and confirmatory of the theory of the primarily local 
nature of the disease. 

The assertion * that diphtheria and syphilis are analogous 
is misleading, since the analogy is at most only a partial one; 
for even admitting that both diseases become constitutional 
simultaneously with the occurrence of the primary lesion 
(which if it be true in diphtheria must in many cases be so in 
only a slight and unimportant degree), yet they differ in these 
two important respects: There is not in syphilis any usual 
proportion between the gravity of the primary and the second- 
ary affections, and the secondary disease goes on independently 
of the primary affection and uninfluenced by treatment ap- 
plied to it. 

^Sanng, loc. cit. 



CHAPTER VI. 

SECONDARY DIPHTHERIA. 

Secondary Diphtheria is that which attacks a person 
who is already suffering* from another disease of which the 
diphtheria is in some degree the result. 

Strictly speaking, a large proportion of all cases of diph- 
theria are secondary rather than primary, since, as has 
already been seen, various catarrhal affections of the mucous 
membranes prepare a favorable soil for the insemination of 
diphtheria. The term secondary, however, is more usually 
applied to that diphtheria which supervenes upon other spe- 
cific diseases. 

Secondary diphtheria is usually subject to the two follow- 
ing laws : (1) It manifests itself only after the primary dis- 
ease has run its active course, or, at least, after its intensity 
has begun to abate. (2) It occurs on those mucous mem- 
branes which have been especially affected, and thus prepared 
for its invasion, by the primary disease. 

Secondary diphtheria, or an affection resembling diphthe- 
ria, undoubtedly occurs with the greatest frequency in con- 
nection with scarlatina. It is a mooted question whether the 
pseudo-membranous formation which so frequently appears in 
the course of this disease is a true and distinct diphtheria, or 
is merely a product of the scarlatinal inflammation. I believe 
that both views are in part correct, or, in other words, that 
there is a very common diphtheroid affection which is merely 
a part of scarlatinal angina, and also that true diphtheria 
very often supervenes upon scarlatina. 



SECONDARY DIPHTHERIA. 105 

It is common to see from the second to the fifth day of 
scarlatina the previously bright red mucous membrane of the 
throat become coated over with a white pellicle which is in 
appearance distinctive. It is thin, filmy, uniform, only slightly 
elevated above the surrounding mucous membrane, is not in 
well-defined sharply limited patches as in the case of true 
diphtheritic membrane, but its borders shade off from the 
unaffected surface by an almost imperceptible gradation. It 
does not lie loosely upon the surface of the mucous membrane, 
nor can it be readily detached from it, but is closely adherent 
to it, and presents to the eye the appearance of being a trans- 
formation in its most superficial epithelial layers, which indeed 
it probably is. It is often quite extensive, covering one or 
both tonsils, one or both faucial arches, the anterior surface 
of the soft palate, the uvula, and in some cases the posterior 
wall of the pharynx. It is accompanied with a more or less 
abundant thin or glairy muco-purulent secretion. It usually 
persists through the active stage of the disease and then melts 
away by desquamation. I have seen this form of affection 
in many cases. It has never produced any of the systemic 
conditions which are peculiar to diphtheria, nor has it been 
followed by paralysis. From this circumstance, from its uni- 
form distinctiveness of character, and from the early stage of 
the disease at which it appears, I regard it fts exclusively a 
result of the scarlatinal inflammation. 

There is a very different affection which usually appears at 
a later stage of the disease — from its sixth to its tenth day or 
even later — when its intensity has begun to abate. This 
commonly commences in the pharynx with the usual symp- 
toms and appearances of faucial diphtheria, including well- 
defined patches of true diphtheritic membrane of varying 
thickness, foetor, adenitis, septicaemia, etc. It has a great 
tendency to extend over the regions which have been most 
affected by the scarlatinal inflammation, especially the nasal 
passages, the Eustachian tubes and the middle ear. It has 



106 diphtheria; its nature and treatment. 

even in some cases invaded the eye by way of the lachrymal 
duct. 

I have seen the first-described affection very common in 
some epidemics of scarlatina at times when diphtheria was 
not at all prevalent, and, on the other hand, have seen the one 
last referred to a very frequent and formidable complication 
or sequel to scarlatina at times when diphtheria was epidemic. 

True diphtheria may supervene upon the diphtheroid form 
of scarlatina, the whole aspect of the case being thereby 
speedily changed. 

It will be seen that unless the distinction which has now in 
its clinical aspects been pointed out be borne in mind, compar- 
ative anatomical observations on the false membranes of scar- 
latina and of diphtheria can have little value, as all forms of 
diphtheritic metamorphosis of tissues are seen in connection 
with scarlatina. Yet Heubner would seem to have had in 
view the diphtheroid pseudo-membrane which I first described 
when he said, 1 " True tissue-diphtheria is beautifully illustrated 
and developed in scarlatina, and differs from it only in this 
respect, that in the latter only the epithelium and superficial 
capillaries are affected, while in the former both mucous and 
sub -mucous layers, including the blood-vessels, are implicated 
in the process of coagulation -necrosis." 

It cannot be'denied that true diphtheria does in exceptional 
cases accompany scarlatina at a very early stage, or may 
even be the prior affection, but in such cases the diphtheria 
can be regarded only as an accidental complication of the 
scarlatina. In the records of many epidemics, especially by 
the earlier writers, as we have seen in the chapter on history, 
the features of diphtheria and of scarlatina are mingled to- 
gether in inextricable confusion, each having resulted from 
the contagion of the other, and not only pharyngeal and nasal 
but laryngeal diphtheria having often been early concomitants 
of scarlatina. Such facts can only be explained by the suppo- 
1 Die Experimentelle Diphtherie. 



SECONDARY DIPHTHERIA. 107 

sition that unusually intense epidemics of each disease were 
concurrent. 

Diphtheria in following" measles conforms to the two general 
rales above stated, in appearing as the eruption and acute 
symptoms of the prior disease are abating (namely after the 
fifth or sixth day of the eruption) and in being localized where 
its principal lesions have occurred. Hence it has been found 
to furnish a particularly large proportion of cases of the 
laryngeal and tracheal affection. For this reason the compli- 
cation is an especially formidable one, the mortality, accord- 
ing to some statistics, being* eighty per cent. (Sanne.) 

Diphtheria has also been a very frequent complication in 
some epidemics of small-pox, and has shown an especial ten- 
dency to affect the larynx and trachea. 1 

In typhoid fever, diphtheria rarely occurs before the end of 
the second week. It frequently affects the larynx, but owing 
to the obtunding of the sensibilities by the disease, and the fact 
that many of the patients are adults, it often fails to be recog- 
nized during life. 

In accordance with the second law above referred to, sec- 
ondary diphtheria is sometimes located in regions which are 
very rarely visited by primary diphtheria. Thus diphtheria 
of the oesophagus is usually consequent upon typhoid fever, 
cholera, measles, scarlatina, small-pox, pulmonary tuberculosis 
and pyaemia, and that of the g-astric mucous membrane upon 
scarlatina and small-pox. (Ziegler.) 

1 Riihle, Die Kehlkopf. Krankheiten, Berlin, 1861, p. 247. 



CHAPTER VII. 

DIPHTHERITIC PARALYSIS. 

One of the most striking- peculiarities of diphtheria is the 
frequency with which it is followed by paralysis. The propor- 
tion of cases in which this sequence has occurred has varied, 
according to different observers, from 1.15 to 66 per cent. Of 
1382 cases observed by Sanne, eleven per cent, were followed 
by paralysis. In view of the liability of very mild cases of 
paralysis to be unrecognized, the estimate of Gowers 1 of 
twenty-five per cent, of all cases is perhaps not excessive. 

Diphtheritic paralysis is usually a sequela, for, while it oc- 
casionally appears early in the course of the primary disease, 
yet in by far the greater number of cases it is first manifested 
in the second or third week, and has occurred as late as the 
fortieth day after the disappearance of the local symptoms. 
It follows the mildest cases as well as the most severe ones. 
According to the statistics of Landouzy 2 the tendency to its 
occurrence is very slight in infants and increases with age. It 
has one usual starting-point, the soft palate, to which in a 
large proportion of cases it is limited. When it invades other 
parts successively there is a certain order of progression 
which, as a rule (though subject to many exceptions), it ob- 
serves. It is, in the great majority of cases, a paresis rather 
than a complete paralysis. It is, as a rule, of comparatively 
brief duration. Its termination, with relatively few excep- 
tions, is in complete recovery. 

Paralysis of the soft palate and pharynx first manifests 

1 " Diseases of the Nervous System," p. 1221. 

2 " Des Paralysies dans les maladies aigues," Paris, 1880. 



DIPHTHERITIC PARALYSIS. 109 

itself by modifications in the voice. Articulation, especially of 
the palatal consonants and vowels, is difficult or impossible. 
Speech may present all grades of imperfection, from a slight 
nasal twang to complete unintelligibility. Deglutition is also 
interfered with in various degrees. In the least degree there 
is experienced a slight slowness or clumsiness in the act of 
swallowing. In a greater degree, liquids are regurgitated 
through the nose. Solids are swallowed more easily, but even 
they in bad cases give much trouble, missing- the oesophagus 
to enter the larynx or to remain in the naso-pharyngeal cav- 
ity. Small portions usually cause more inconvenience than 
larger quantities. This interference with swallowing in some 
cases makes the taking of necessary nourishment a matter of 
extreme difficulty. Expectoration, or the expulsion of mucus 
from the throat and nasal passages, is in like manner rendered 
difficult or impossible. 

If the mouth be opened the soft palate is seen to hang re- 
laxed and motionless. When the paralysis is unilateral it is 
drawn toward the healthy side. It has partially or wholly 
lost its sensibility and does not respond to tickling or irrita- 
tion by the usual reflex movements. The muscles of the 
tongue, lips, and face are sometimes affected. 

Disturbances of vision are of frequent occurrence. They 
usually appear soon after the commencement of the palatal 
paralysis, but in rare cases simultaneously with it or even 
before it. The most common form is asthenopia. There is 
difficulty in reading fine print or distinguishing other small 
objects. Efforts to do so are quickly followed by fatigue and 
blurring or flashes of light before the eyes. The vision of dis- 
tant objects is not usually impaired. These symptoms are 
due, according to the researches of Donders, 1 mainly to de- 
fective accommodation from paresis of the ciliary muscles. In 
some cases there are diplopia, vertigo and strabismus of one 
or both eyes, from the involvement of the oculo-motor mus- 
1 British Med. Jour., May 12th, 1877, p. 505. 



110 diphtheria; its nature and treatment. 

cles, and more rarely ptosis, from implication of the levator 
palpebral superioris. 

Next in order of occurrence are paralyses of the muscles of 
the extremities, those of the lower extremities being- usually 
the first, and sometimes the only ones, to be affected. The 
affection commonly begins with disturbances of sensation, 
such as feelings of coldness, numbness, tingling or sharp 
pains. Various degrees of feebleness in some or all of the 
muscles concerned in locomotion are next experienced. The 
ground often feels soft and yielding from impairment of the 
muscular sense. Cutaneous sensibility is sometimes abolished, 
especially- in the soles of the feet. Anaesthesia is sometimes 
accompanied with analgesia, which may be general in the ex- 
tremity affected or confined to limited* areas. Sometimes the 
symptoms are those of ataxia. The movements are incoordi- 
nate and the patient cannot walk with his eyes closed. The 
affection of the muscles rarely exceeds a greater or less degree 
of paresis, and is often, as in other situations, limited to par- 
ticular muscles or groups of muscles, but in rare cases abso- 
lute paralysis of the lower extremities ensues. • In proportion 
to the degree and duration of the paralysis there are flabbi- 
ness and a tendency to atrophy of the muscles. 

A similar order of symptoms may occur in the upper ex- 
tremities. Tactile sense in the fingers is diminished or lost. 
The affection is more usualry partial and limited to certain 
muscles, causing tremor or choreic movements, and feebleness, 
clumsiness and uncertainty in the use of the hands and arms. 
In rare cases the paralysis here also becomes complete. 

Diphtheritic paralysis in the extremities is most usually 
symmetrical, though often somewhat unequal in the two sides. 
Its absolute limitation to one side is very rare, though not 
altogether unknown. 

Diphtheritic paralysis of the muscles of the larynx seldom 
occurs alone or in connection with that of the pharynx merely, 
but usually appears only in the course of more general paral- 



DIPHTHERITIC PARALYSIS. Ill 

ysis. It may be limited to one muscle or may be general. Its 
presence may be recognized by modifications in the quality of 
the voice, varying", according to the extent and degree of the 
affection, from slight roughness or loss of resonance to abso 
lute aphonia. Tranquil respiration is not seriously interfered 
with, bat coughing, forcible expiration, and "holding the 
breath" are rendered difficult. Loss of sensibility in the 
laryngeal mucous membrane sometimes accompanies the 
motor paralysis. From this cause portions of food have en- 
tered the larynx unperceived by the patient and have caused 
death by suffocation. This accident may also result from 
sensory and muscular paralysis of the epiglottis. 

On laryngoscopic examination it is found that one or both 
vocal cords have lost in part or wholly their motility. When 
only one muscle is affected the position of the vocal cord is 
fixed by the antagonistic action of the non-paralyzed muscles. 
When the paralysis of the laryngeal muscles is general, the 
vocal cords are motionless midway between the positions of 
phonation and of respiration, as in the cadaver. 

Paralysis of the muscles of the neck and trunk is usually 
one of the latest developments in general diphtheritic paraly- 
sis. When the former are seriously affected the patient is 
unable to raise or hold up or turn the head, which droops help- 
lessly. When the latter are paralyzed he is similarly deprived 
of the power to hold the body upright, or even to turn in bed. 
Implication of the intercostal muscles causes serious embar- 
rassment to respiration. When the diaphragm is also in- 
volved, the shallowness and difficulty of breathing are greatly 
increased, and in proportion to the degree of the paralysis 
there are cyanosis and liability to death from asphyxia. 

The heart is also affected by diphtheritic paralysis, and to 
this fact is due by far the greatest number of its fatal results. 
The time at which this affection occurs varies widely. It some- 
times takes place in the second or third week of the primary 
disease, or, in rare cases, even earlier, and, on the other hand, 



112 diphtheria; its nature and treatment. 

is not infrequent in advanced convalescence, and is usual in 
the course of general diphtheritic paralysis. 

Its severity and fatality are, as a general (though not inva- 
riable) rule, greatest when it occurs early. Even then it has 
usually been preceded by palatal or pharyngeal paralysis, 
though it is not impossible that the heart should be the part 
first affected. Its onset in this form is usually sudden. It is 
often attended with a rigor or a sensation of chilliness. It is 
frequently preceded or accompanied with symptoms of gas- 
tric disturbance and failure of digestion, such as nausea, ano- 
rexia, etc. There is a sudden accession of dyspnoea and precor- 
dial oppression. The countenance expresses distress and 
alarm, and its hue is pale or cyanotic. The surface, especially 
of the extremities, is cold. The pulse is weak, fluttering, in- 
termittent and variable, the heart-sounds inufned, confused 
and irregular. Death may ensue quickly, or only after a 
number of hours, or the attack may be partially recovered 
from only to return again, or (too rarely) the recovery may 
be complete and permanent. Cadet de Gassicourt records 
only one recovery in fifteen such cases. 

As it occurs at a later period, diphtheritic paralysis of the 
heart, like that of other organs, varies from a slight and 
transient paresis to a suddenly fatal cessation of function. In 
the whole number of cases the fatal results are doubtless f^wer 
than the recoveries. 

During the continuance of cardiac paralysis there is great 
liability to an aggravation of the condition by exertion, even 
the slightest effort having in many cases been followed by a 
fatal result and in others by alarming but transient symp- 
toms of heart-failure. An interesting case of a practicing 
physician of this city, as related by himself, is published by 
Dr. A. D. Rockwell. 1 In this case "cardiac difficulty," paresis 
of soft palate, pharynx and larynx, of ciliary muscles, of upper 
extremities, of lower extremities and of bowels, appeared in 
'"Medical and Surgical Elec 1-1-10117," p. 629. 



DIPHTHEKITIC PARALYSIS. 113 

the order mentioned, beginning- about the third week after the 
disappearance of the diphtheritic patches and ceasing- in the 
sixteenth week, except that slight cardiac feebleness remained 
for fifteen months. The cardiac difficulty mentioned was in- 
dicated by a very feeble, soft, slow pulse averaging sixty per 
minute. "On one occasion, immediately following special ex- 
ertion, the pulse quickly rose to 160 and as quickly fell to 32 
per minute, resulting in an attack of angina pectoris, which 
persisted for nearly three hours. This sudden fluctuation of 
the pulse was most alarming, and caused apprehension of im- 
mediate dissolution." It is also stated that the symptoms, 
not only of the cardiac but of the other paralysis, " were in- 
variably increased by the slightest exercise." 

The walls of the intestines and of the bladder and also their 
sphincters are occasionally affected with diphtheritic paraly- 
sis, producing in the former case retention of their contents, 
and in the latter involuntary fecal movements or incontinence 
of urine. Anaphrodisia and impotence are not infrequent 
sequela?. Pararyses of the special senses, such as temporary 
amaurosis, deafness, and impairment in various degrees of 
taste and smell, have been observed. Anaesthesias and dyses- 
thesias have also occurred without accompanying motor pa- 
ralysis. 

While the order of occurrence of the various localizations 
of diphtheritic paralysis which has now been indicated is a 
usual one, it is far from being invariable, and they may take 
place successively in any order whatever, or any number of 
them may be present at the same time. Thus, in the case of a 
physician, reported by himself, 1 the order of events was as fol- 
lows: Pains in axilla, arms and hands; motor paralysis of 
lower extremities; loss of sensation in limbs and trunk; sen- 
sory and motor paralysis in upper extremities; loss of sensa- 
tion in mouth, tongue and portions of face; paralysis of soft 
palate; dimness of vision; increase of motor and sensory 
1 Dr. Reed, Boston Med. and Surg. Journal, July 13th, 1876. 



114 diphtheria; its nature and treatment. 

paralysis in arms and hands; paralysis of bladder; loss of 
power of erection ; paralysis of interosseous muscles. 

The duration of diphtheritic paralysis is generally in pro- 
portion to its severity. I have seen a paresis of the soft palate 
entirely disappear within eight days from its commencement, 
and from two to six weeks is a frequent duration. More gen- 
eral cases may last for as many months, and in rare instances 
some of the symptoms persist for years. 

The small proportion of cases which terminate fatally do 
so from inanition caused by difficulty in swallowing, from the 
effects of the entrance of foreign bodies into the air-passages 
in pharyngeal and laryngeal paralysis, and from pulmonary 
affections produced or aggravated by that paralysis, from 
asphyxia in paralysis of the respiratory muscles and from 
heart-failure in cardiac paralysis. 

The reaction to electricity in many cases of diphtheritic 
paralysis is not perceptibly altered. In severe ones farado- 
muscular contractility is usually diminished, while galvano- 
muscular contractility continues normal or is exaggerated. 
In grave cases of long duration, in which the muscles are 
atrophied, their contractility under the galvanic current is 
diminished or lost. Thus the reactions to electricity in diph- 
theritic paralysis are generally those of peripheral nerve de- 
generation, as has been pointed out by Ziemssen x and many 
subsequent writers. 

The onset of diphtheritic paralysis is usually, though not in- 
variably, accompanied by the loss of the knee-jerk. The re- 
markable fact was discovered by Bernhardt 2 that the knee- 
jerk is abolished, not only in actual diphtheritic paralysis, but 
in a large proportion of all cases of convalescence from diph- 
theria that are unattended by recognizable paralysis. In 
twenty-one such cases examined by him the knee-jerk contin- 
ued on both sides in seven, but was absent on one side in one, 

1 Berl. Klin. Wochenschrift, 1866, Nos. 43 and 44. 
2 Virchow , s Archiv., 1885, Bd. 99, p. 293. 



DIPHTHERITIC PARALYSIS. 115 

and on both sides in thirteen, the loss occurring" in two-thirds 
of his cases. This observation has since been abundantly con- 
firmed. The abolition of the knee-jerk usually occurs in the 
latter part of the first month after the onset of the primary 
disease, or in the course of the second month, and continues 
for four or five months. Its disappearance is frequently pre- 
ceded by its temporary exaggeration. Its return is at first 
unilateral and is gradual, there being alternations of its occur- 
rence and its non-occurrence. The knee-jerk may be present 
in post-diphtheritic ataxia, and may be absent when there is 
no ataxia. 

Loss of knee-jerk also occurs at an early stage of some' 
cases of diphtheria. Dr. R. L. McDonnell 1 states that in eigh- 
teen cases of diphtheria in the Montreal General Hospital, 
knee-jerk was absent at the time of admission in 10, and pres- 
ent in 8. 

Albuminuria is a frequent, but not a constant, accompani- 
ment in grave cases of diphtheritic paralysis. Thus of sixteen 
fatal cases described by Abercrombie, albuminuria occurred 
in one fourth. 

The anatomical changes which have been observed in fatal 
cases of diphtheritic paralysis have been elsewhere described 
(page 65). They consist in inflammatory and atrophic 
changes in the gray matter of the anterior horns of the spinal 
cord; inflammatory or degenerative lesions of peripheral 
nerves; changes in the vascular system and its contents, and 
atrophic changes in muscles. 

The changes in the nerves are in the greater number of 
cases primarily and mainly in the nerve-elements themselves 
rather than in the investing or interstitial tissues. They are 
characteristic of "parenchymatous neuritis," a degenerative 
condition which may begin at any point in the course of a 
nerve, or may be consecutive to lesions in the spinal nerve- 

1 Medical News, October 15, 1887, p. 448. 



116 DIPHTHERIA; ITS NATURE AND TREATMENT. 

cells. It extends downward in the course of the nerve from its 
point of commencement, but not upward. 

In other cases inflammatory changes in the interstitial 
elements of the nerves predominate. Interstitial neuritis, un- 
like the parenchymatous, may extend upward in the nerve. 
Its occurrence in the palatine nerves may he due to the prox- 
imity of their terminal filaments to the seat of the primary 
diphtheritic inflammation and their consequent exposure to 
the direct action of the poison there evolved. That this is the 
case in some of the instances in which the diphtheritic inflam- 
mation in the soft palate is intense and the paralysis in that 
situation occurs early is not improbable. That the usual com- 
mencement of diphtheritic paralysis in the soft palate cannot 
in all cases be thus explained is shown by the facts of patho- 
logical anatomy above referred to, and also by the clinical 
facts that paralysis often occurs when the pharyngeal inflam- 
ation has been extremely slight and fails to occur when it 
has been intense, and that palatal paralysis has appeared in 
some cases in which there has been no sore throat, the diph- 
theritic inflammation having occurred on wounds, etc. in re- 
mote situations, and that paralysis following pharyngeal 
diphtheria sometimes commences in remote parts of the body. 
Yet such cases must be regarded as exceptional, the general 
fact being that diphtheritic paralysis usually commences in 
what may be called regional proximity to the site of the origi- 
nal disease. Trousseau, after referring to several of the cases 
just alluded to, adds, " Generally, however, where the paraly- 
sis is consecutive to cutaneous diphtheria it commences in the 
extremities;" and many recorded cases support this state- 
ment. 

It must be remembered that the anatomical lesions above 
referred to, occurred in fatal cases. That in ordinary cases 
the} 7 are far less grave is evident from the clinical fact that 
recovery in them is usually speedy and almost always com- 
plete. Yet it is reasonable to suppose that the difference is 



DIPHTHERITIC PARALYSIS. 117 

rather in degree than in kind, the disturbance in the nutrition 
of the nerves affected varying- through all gradations from 
that which is so slight as to be manifested only in a transient 
and scarcely perceptible impairment of function to that which 
is destructive and fatal. The generally accepted view of the 
pathology of the most usual forms of diphtheritic paralysis is 
stated by Dr. T. Buzzard 1 as follows : "I do not think that 
with the clinical evidence before us we are justified in saying 
that diphtheritic paralysis in its ordinary form, passing- to 
complete recovery, is dependent upon an affection of the spinal 
cord. It is, in my opinion, more reasonable to conclude that 
in this disease we have usually to do with peripheral neuritis 
of very varying- severity, which in the mildest cases is proba- 
bly represented by a mere transitory hyperaemia with effusion 
in the interstitial element." 

The precise mariner in which diphtheria causes diphthe- 
ritic paralysis has not yet been demonstrated. It has been 
held by many that the disturbance of nutrition in the nervous 
system which underlies the paralysis is wholly or mainly due 
to the anasmia which is a striking characteristic of convales- 
cence from diphtheria. This view is negatived by the fact 
that paralysis often occurs in cases in which anasmia is slight- 
est and fails to occur in those in which it is most marked, and 
moreover that in other conditions in which anasmia is equally 
profound the symptoms which are peculiar to diphtheritic 
paralysis are unknown. 

A consideration of the pathological and clinical facts which 
have now been referred to, in connection with what has else- 
where been stated in reference to the pathology of diphtheria, 
can leave no reasonable doubt that diphtheritic paralysis is 
due to the action upon the nervous system of a poison, the 
presence of which in the organism is in some way the result of 
diphtheria. It is also highly probable that that poison be- 
longs to the class of ptomaines. But the exact nature of that 
1 Lancet, Dec. 19, 1885, p. 1128. 



118 DIPHTHERIA; ITS NATURE AND TREATMENT. 

poison and of its action upon the nervous system is involved 
in no little obscurity. It has been assumed by some that it is 
the diphtheritic virus itself; but opposed to that view are the 
facts that paralysis follows only a small proportion of all 
cases of diphtheria, and that the probability of its occurrence 
and its severity when it occurs bear no relation whatever to 
the character of the primary disease, and also that in some 
cases it commences weeks after the cessation of the primary 
disease, and only reaches its height several months later. 
The loss of the knee-jerk is also without known definite rela- 
tion to the character of the disease and to the subsequent 
occurrence of paralysis. Many circumstances favor the hy- 
pothesis that the cause of diphtheritic paralysis is a distinct 
nerve-poison concomitant to or resultant from the diphtheritic 
virus, and generated in the system along' with it or subse- 
quently during the period of convalescence in some cases, but 
not in others. In support of this theory the following remark- 
able facts are cited by Gowers 1 from Boissarie : " In a certain 
district of Paris there occurred a series of cases of severe 
diphtheria, and at the same time a series of cases of paraly- 
sis of the palate, eyes, limbs, heart, etc. perfectly like that 
which occurs after diphtheria, and accompanied by albuminuria. 
The remarkable fact is that in these cases of primary palsy 
there was no history of preceding sore-throat, and in several 
of the cases distinct diphtheria followed the paralysis, which 
lessened during the throat-affection. Some of the cases of 
primary palsy seemed to arise distinctly by infection." 

Dr. W. H. Thomson says: 2 "Our knowledge of the action 
of the micro-organisms is sufficiently advanced now for us to 
know that some of them evidently cause disease by generating 
definite poisons or ptomaines, which are absorbable into the 
blood, and then act there just as other poisons act, some of 
them as even arsenic does, causing multiple neuritis of a dis- 
seminated and yet selective kind It becomes quite 

1 Op. cit., p. 1233. 2 Loc. cit. 



DIPHTHERITIC PARALYSIS. 119 

conceivable to infer that the working* of the diphtheritic or- 
ganism may prepare, in certain cases, the way for some subse- 
quent process in the body by another organism, when the 
conditions for its growth have been fulfilled by the antecedent 
presence of the diphtheritic agent, and that it is during this 
subsequent process that the poison which works such mischief 
on the nervous mechanism is produced." 

The probability that this poison causes paralysis in most 
cases by producing trophic disturbances of very various de- 
gree in the peripheral nerves has already been referred to. 
That in some cases it has a direct and powerful paralyzant 
effect upon the nerves by arresting- their function without pro- 
ducing any appreciable structural lesion has been shown in 
various autopsies. That this may probably be its action in 
cases of early and sudden heart-failure, and also in other 
forms of early and transient diphtheritic paralysis has recently 
been shown with much force of reasoning by Dr. J. Lewis 
Smith, 1 the principal arguments adduced being the following : 
Ptomaines spring into existence suddenly and unexpectedly 
under favoring conditions. Cases occur in which carefully con- 
ducted microscopic examinations reveal an apparently normal 
state of the nerves supplying the paralyzed part, and of that 
part of the cerebro-spinal axis from which the nerves arise, 
and also, in cases of heart-failure, of the heart itself. Palatal 
paralysis sometimes occurs as early as the second or third 
day of diphtheria, and loss of the tendon-reflex as early as the 
first day; and it seems improbable that a peripheral neuritis 
or anatomical changes in the cerebro-spinal axis, such as to 
cause paralysis, should occur at so early a date. In its com- 
mencement diphtheritic paralysis often suddenly shifts from 
one group of muscles to another, or there is a sudden recovery 
from it on one day, and a recurrence of it on the next; which 
would seem impossible if it resulted from degenerative nerve- 

1 " Sudden Heart-Failure in Diphtheria ; its Pathology and Treat- 
ment," Medical News, Nov. 10, 1888, p. 536. 



120 diphtheria; its mature and treatment. 

changes, either central or peripheral. The incomplete or par- 
tial character of the degenerative changes in peripheral nerves 
which have been observed by some microscopists would hardly 
account for the complete paralysis which often exists, for in- 
stance, in the velum palati. 

The various facts which have now been referred to seem to 
warrant the following general conclusions: 1. "It may be 
positively asserted that diphtheritic paralysis does not in 
every case depend on one and the same cause" (Jacobi). 2. 
The early forms of the affection are probably due mainly to a 
direct inhibitory effect upon nervous function either of the 
diphtheritic poison or of some other poison which is often, but 
not necessarily, associated with it. 3. The later forms of the 
affection result from pathological changes in the nervous sys- 
tem, the most usual form of which is parenchymatous or degen- 
erative peripheral neuritis — these changes being initiated by 
the diphtheritic poison or poisons and favored by the impover- 
ished condition of the blood. 



CHAPTER VIII. 

DIAGNOSIS. 

The recognition of grave forms of diphtheria, when fully 
developed, is usually easy; but then the recognition is often too 
late. It is the earlier stages and milder forms of the disease 
which need to be intelligently discriminated from certain affec- 
tions which often bear an astonishingly close resemblance to 
them; and this discrimination, its essential principles being 
understood, is in most cases not difficult. 

The first essential in this diagnosis is complete and accu- 
rate- observation. 

As oir~ patients are mostly children, the laryngoscopic and 
rhinoscopic mirrors are for obvious reasons not usually very 
available, nor are they generally necessary, though in some 
cases, especially in older patients, they may give valuable in- 
formation. 

The patient should be placed for examination directly in 
front of a window or a good artificial light — if a young child, 
on the lap of his nurse. Thorough inspection of the throat is 
now in most cases easy. But some young children will oppose 
the operation. When this disposition is manifested the nurse 
should secure the patient's hands while some other person 
stands behind him and holds his head between the palms of 
the hands. Then, if the lips and teeth are compressed, the 
tongue-depressor (a smooth spoon-handle is one of the best) 
should not be thrust forcibly in, but held in readiness await- 
ing the opportunity which the child will soon give. It is then 
slipped deftly between the teeth and well back into the mouth 
along the dorsum of the tongue, when gentle pressure down- 



122 diphtheria; its nature and treatment. 

wards will cause the child to open his mouth and give a view 
of the throat. The conformation of the mouth and throat is 
so different in different persons that it is now and then a 
matter of some difficulty to obtain a satisfactory view of the 
throat, especially if the patient resists or is inclined to vomit. 
In such cases some perseverance may be necessary. Repeated 
attempts with a little interval between them are less likely to 
excite vomiting- than retaining the tongue-depressor in posi- 
tion too long- at one time. The very act of " gagging " will 
throw the tonsils forward, giving* a view of their posterior 
surface. 

The throat having- been thus thoroughly inspected, perhaps 
only redness and more or less swelling are observed. Do these 
denote the catarrhal or ante-membranous stage of diphtheria 
or some other inflammation of the throat ? The probability 
of its being the former will be favored by the fact of previous 
exposure to contagion or the presence of an epidemic, and by 
certain characteristics of the throat-inflammation, especially 
a certain intensity and a somewhat abrupt limitation to a 
particular location, as one tonsil or one faucial pillar or a por- 
tion of the soft-palate; but it is only occasionally that this 
evidence is very significant. Other forms of throat-inflamma- 
tion, as the follicular, are often one-sided, and I have seen the 
aspect of the throat in diphtheria a few hours before the ap- 
pearance of membrane in no way distinguishable from that of 
many ordinary sore-throats. Hence a positive diagnosis of 
diphtheria can but rarely be made at this stage. 

But suppose that we see on the inflamed mucous mem- 
brane of the throat whitish, yellowish or grayish appearances 
which at the first view more or less resemble false membrane. 
It is safe to say that a diagnosis of diphtheria or of " diphthe- 
ritic sore-throat " based simply on them would in the large 
majority of cases be erroneous. 

It may be remarked in passing, that the phrase, diphthe- 
ritic sore-throat, may indeed have a legitimate use to convey 



DIAGNOSIS. 123 

a definite and well -understood meaning-; but it has far too 
commonly been vaguely and indiscriminately applied in the 
absence of a positive diagnosis to various mild diphtheroid 
affections, most of which are, in no true sense of the word, 
diphtheritic. 

The one pathognomonic sign of diphtheria is diphtheritic 
false membrane. The existence of diphtheria without a diph- 
thera is indeed asserted. The reasons for regarding its oc- 
currence as improbable have been elsewhere given. The 
distinctive characteristics of diphtheritic false membrane 
have elsewhere been stated. This membrane in the fauces 
and pharynx is never altogether superficial to the mucous 
membrane. Though the depth to which it involves the epithe- 
lial layers varies greatly in different cases, yet even in its 
most superficial form it is so intimately connected with the 
subjacent tissues that if it be scraped or torn away, a raw 
and bleeding surface is exposed. 

In non-diphtheritic pharyngitis we often see whitish patches 
of pultaceous follicular secretion or smearings of glairy tena- 
cious mucus, or ulcers of various kinds covered over with, or 
surrounded to some little distance by, yellowish or grayish 
muco-pus, or, in some cases, with a superficial and fragile 
membranous formation which is undoubtedly a true fibrinous 
or croupous exudation. These forms of ulcerative pharyn- 
gitis have been variously designated as "ulcero-membranous 
angina" by Da Costa, 1 "common membranous sore -throat" 
and "herpetic sore-throat," by J. Solis-Cohen, 2 "confluent 
herpes of the throat " by Morell Mackenzie, 3 and " drain- 
throat," a form of septic sore-throat attended with ulceration, 
by S. Solis-Cohen. 4 

The appearances presented by these affections may at the 

1U Medical Diagnosis," Phila., 1881, p. 431. 

2 "Diseases of the Throat," New York, 1879, p. 103. 

3 Op. cit., p. 52. 

4 "The Diphtheroid Throats," Archives of Paediatrics, February, 
1888, p. 92. 






124: diphtheria; its nature and treatment. 

first view be very deceptive to the inexperienced eye ; but their 
true character may he readily ascertained by brushing- them 
with a swab, or, still better, throwing* a stream of water upon 
them from a syringe. In aphthous or herpetic angina the 
little vesicles and the resulting ulcers are readily recognized 
when clearly exposed to view by this method, and the fibri- 
nous pellicles just referred to have entirely vanished from the 
scene, or just enough . fragments of them remain to make 
clearly evident their fragile, superficial and non- diphtheritic 
character. 

But by far the most frequent occasion of error in diagnosis 
is the very common affection known as acute follicular or 
lacunal tonsillitis. The tonsils are irregularly ovoid bodies, 
the surface of which is penetrated by a varying number of 
slit-like or circular orifices of a system of internal cavities, 
crypts or lacunae, from which numerous follicles branch out 
into the substance of the gland. " The crypts of largest size 
and greatest depth are as a* rule found in the middle part of 
the tonsil. (See figure 9.) The crypts are generally filled 
more or less with a yellowish substance composed of fab 
molecules, loosened pavement epithelium, lymph corpuscles, 
small molecular granules and cholesterin crystals, which prob- 
ably proceed from retained and decomposed epithelial matter, 
and perhaps now and then from the bursting of follicles whose 
cells have increased by proliferation and have undergone a 
retrograde metamorphosis and fatty degeneration." 1 

Acute follicular tonsillitis occurs sporadically in connection 
with ordinary catarrhal pharyngitis, endemically from vari- 
ous local insanisary conditions, and epidemically. In this last 
form it is undoubtedly a specific disease, and is probably in 
some degree contagious. I have been led to this last conclu- 
sion from having so often seen it go through families of chil- 

1 From " The Tonsils, their General, Surgical and Minute Anatomy," 
by D. Bryson Delavan, M.D., Archives of Laryngology, December, 

1880. 



DIAGNOSIS. 



125 



dren, successive cases occurring- at intervals of one, two or 
three days, just as occurs with diphtheria or scarlatina. 

Follicular tonsillitis is not a milder grade of diphtheria, 
but is a totally distinct disease. Diphtheria, it is true, may 
supervene upon follicular tonsillitis, as upon other catarrhal 




Fig. 



-Hypertrophied Tonsil. (Enlarged drawing, Luschka.) This figure shows the 
tion of the lacunae and their orifices iu the tonsil, as is above described. 



affections, but then it is usually, at least, only after the latter 
has run its course. As this requires only a few days, it is not 
strange that the two affections have been supposed by some 
to be related. 

Follicular tonsillitis differs from diphtheria in not causing 
constitutional poisoning, either septic or specific. It is not 



126 diphtheria; its nature and treatment. 

accompanied with nephritis (except as any febrile catarrhal 
affection may occasionally be); it is not followed by paralysis, 
and I have never known of a fatal case. 1 

The onset of follicular tonsillitis is undistinguishable from 
that of diphtheria in the amount of febrile and nervous dis- 
turbance which accompanies it. Its second stage, that of fol- 
licular exudation on the inflamed tonsil, may closely resemble 
diphtheria. Its third stage, which occurs after two or three 
days, is that of the disappearance of this exudation, exposing 
in its place peculiar appearances of erosion or excavation in 
the surface of the tonsil. 

In the second stage, or that of exudation, we may often see 
whitish or yellowish points projecting, or liquid oozing from 
one or more of the lacunal orifices of the tonsils. The diag- 
nosis is then easily made, for these appearances are pathog- 
nomonic of follicular tonsillitis. It is made easy in other 
cases by the evidently soft and pultaceous character of the 
deposit on the tonsil, and by its lying loosely and superficially 
on its surface, from which it is easily removed by rubbing it 
with a swab. 

There is a smaller proportion of cases, but yet very numer- 
ous in the aggregate, in which the diagnosis is much more 

1 In the Section on Practice of the New York Academy of Medicine, 
Dr. J. Lewis Smith (see New York Medical Record, Nov. 27th, 188G) 
stated as the result of his large observation of the tAvo diseases his belief 
that they are not related, except that diphtheria may occur as a 
secondary disease. Dr. L. Emmet Holt, from the observation of three 
hundred recorded cases of tonsillitis, concurred in this view. Dr. Holt 
also quoted Dr. Haig-Brown, medical officer to the Charterhouse 
school in England, who had in three years met with four hundred and 
sixteen cases of tonsillitis among the five-hundred boys who were under 
his supervision, but only one case of genuine diphtheria, and who had 
recorded two epidemics of simple tonsillitis in which the disease was 
unquestionably spread by contagion, and Dr. Gr. A. Spalding of this 
city, who had stated that at the House of Refuge cases of tonsillitis 
were constantly occurring, yet no clear case of diphtheria had been 
seen there in years, and Dr. Gibney of this city, who had made a similar 
statement in reference to the Hospital for the Ruptured and Crippled 
during his term of service there. 



DIAGNOSIS. 127 

difficult. These cases are thus described by Dr. Geo. M. Lef- 
ferts : x " Have you not often seen in these cases of follicular 
tonsillitis an aggregation of the grayish- white pultaceous 
masses which block up the mouths of the diseased and oc- 
cluded crypts to such an extent that not only is an apparent, 
but a real pseudo-membrane formed — one thickened by the 
products of cellular growth and decay (fungi and bacteria) 
and rendered coherent by the inflammatory hyperplasia ? A 
membrane which may occupy only part of the tonsillar sur- 
face appears here and there in patches, or, more rarely, still 
not infrequently, covers it entirely. The appearance is not an 
unusual one, and the attendant constitutional disturbance 
well-known." 

Dr. Lefferts in this connection refers also to the infectious 
catarrhal tonsillitis which has been described by Fox and 
other English writers, under the name of " spreading quinsy," 
which is essentially an inflammation of the tonsils, extending 
more or less into the pharynx, and, sometimes, to the neigh- 
boring submaxillary and cervical glands. It is essentially a 
filth-disease, is communicable, is attended with a certain 
amount of anaemia and depression, the mortality from it is 
slightly greater than from ordinary tonsillitis, and it is never 
followed by paralysis. According to Fox's observations it is 
never accompanied with a well-marked membrane. In this 
respect my own observations have differed from those of Dr. 
Fox, as I have seen more than one epidemic of an affection 
answering in all other respects to the description just given, 
in which the occurrence of quite a firm membranous forma- 
tion on the tonsil was not uncommon. 

While the patches in follicular tonsillitis are more usually 
composed of the conglomerate follicular exudation above re- 
ferred to, spread out and inspissated, they are not infrequently 
either wholly or in part a true fibrinous or " croupous " mem- 

1 " Some of the Commoner Affections of the Tonsils," New York 
Medical Record, 1879, 16, p. 601. 






128 diphtheria; its nature and treatment. 

brane. These two elements are often intermingled. The 
fibrinous form has been regarded and described by some as a 
separate affection from follicular tonsillitis, under the name of 
croupous tonsillitis. Though some cases apparently justify 
this discrimination, yet my observation, which has included a 
great number of cases, has led me to regard them as being, 
usually, at least, simply different forms of the same affection. 
The other view is taken by Dr. L. Emmet Holt in a very val- 
uable paper on the subject; 1 but the following passage in Dr. 
Holt's paper would seem to favor my own conclusion. Having 
referred to other designations given to this affection (" spread- 
ing quinsy/' " catarrhal diphtheria," etc.), Dr. Holt continues, 
"I prefer, with Carmichael, 2 to regard them as cases of croup- 
ous tonsillitis. This writer describes the pathological appear- 
ances in the following words : ' The gland is a pale red ; the 
patch of a yello wish -white color, confined to the tonsil, easily 
separated, leaving a loss of epithelium, but the gland otherwise 
intact. Microscopically, besides the cell-elements of follicular 
tonsillitis, blood-corpuscles in a fibrinous matrix are present.' " 
The italics are mine. Yet my own observations accord with 
those of Dr. Holt that in some cases the fibrinous or " croup- 
ous" element in the affection is the only noticeable feature. 
Our observations agree upon the important points that it is 
limited to the tonsil, that it closely resembles diphtheria, for 
which it is doubtless very often mistaken, and that it is not 
diphtheria. Indeed the only explanation of the fact that the 
descriptions of this very common affection in medical litera- 
ture are so few and, with a few exceptions, so incomplete, is 
that it has been regarded by a large proportion of observers 
as a form of diphtheria. The error is a very natural one. 

The following case is described by Dr. Holt and stated to 
be one of nineteen in all essential respects similar to it of 



1 " The Non-identity of Croupous Tonsillitis with Diphtheria,'" Trans- 
actions of the Medical Society of the State of New York, 1886, p. 552. 
2 Edinburgh Medical Journal, July, 1884. 



DIAGNOSIS. 129 

which he has notes: "On November 11, I saw a stout well- 
nourished girl of ten years, who was reported to have been 
perfectly well until the morning' of that day. She was taken 
at eleven o clock with a chill, vomited twice, complained of 
pains in the chest and seemed quite sick. The temperature, 
when seen three hours later, was 103.2° F., pulse 140, respira- 
tion 32. Examination of the chest revealed nothing abnormal, 
but on inspecting the throat the tonsils were found much 
swollen, and the right completely covered by a thick yellowish 
gray membrane, the left being about two-thirds covered. On 
the following day the temperature was 102.4°, the membrane 
was still distinctly circumscribed, showing no tendency to 
spread, but was more yellow in color. On the third day the 
temperature was 101.6°, and after that it was normal. On 
the fourth day the throat was practically well." 

This case is a graphic illustration of what I have seen 
in numerous instances, and have referred to in previous 
publications, the first having been in 1880. In that paper 
I referred to cases which I had observed of even a more 
deceptive character than the one just described, as follows: 
" In occasional instances nearly the whole surface of the tonsil 
is covered with a thick and firm investment of this character. 
If this appearance is accompanied, as it sometimes is, with 
grave constitutional disturbance, distress and prostration; if 
there is some enlargement of cervical glands; if the throat is 
filled with tenacious muco-pus, perhaps rendered sanious by 
points of ulceration; if there is foetor of the breath; if on the 
uvula or the faucial pillars are the whitish smearings above 
referred to, the physician who has not studied this subject 
carefulry and well naturally supposes that he has to do not 
only with a case of diphtheria, but a grave one, and is de- 
lighted at his success in curing it in two or three days, as he 
is certain to do." 

But it may be asked, what ground of certainty is there that 

such a case is not in reality diphtheritic ? I answer, this — 
9 



130 diphtheria; its nature and treatment. 

that having- recognized its true character by the methods now 
to be stated, Ave can accurately predict the subsequent course 
of events, which is that it will not extend beyond the tonsils, 
and that after two or three days the diphtheroid deposits will 
have vanished, leaving in their place the typical appearances 
of erosion or excavation in the tonsil, and that there will be 
none of the distinctive constitutional symptoms, nor the 
sequelse of diphtheria. 

How shall the differential diagnosis be made ? Not by the 
circumstance that the exudation is limited to the tonsil or 
tonsils, for that is often true in diphtheria ; nor by its short 
duration, for that is equaled by very mild forms of diphtheria; 
nor by the severity or mildness of the accompanying febrile 
disturbance, for that varies greatly in both affections ; nor by 
the test of infection or non-infection, for catarrhal tonsillitis 
is sometimes infectious; nor even by the presence or absence of 
albuminuria, for reasons which have been elsewhere stated. 

We are told by various waiters that the diagnosis of follic- 
ular tonsillitis may be made by scraping the membraniform 
investment from the tonsil, or forcing out the cheesy contents 
of the crypts by pressure, or thrusting a probe into the dis- 
tended lacunal orifices, which methods in the case of a suffer- 
ing and struggling child are unnecessarily heroic. 

In the paper from which I have just quoted I called atten- 
tion to two points or methods in this diagnosis, of which 
experience had taught me the valuable practical utility, and 
the added experience of subsequent years has only tended to 
confirm my estimate of that utility. 

The first of these points is the location of the membrani- 
form patches in follicular tonsillitis. These patches being 
usually formed wholly or in part by exudation from the lacu- 
nal openings, or being at least the result of an inflammation 
which involves the follicular portion of the tonsil, are in rela- 
tion to those openings, and are consequently located on the 
more central portion of the convexity of the tonsil which is 



DIAGNOSIS. 131 

the site of the principal and most numerous openings. (See 
figure 1, page 134). 

On the other hand, a patch of true diphtheritic membrane 
when it is limited to the tonsil is not usually seen on that por- 
tion of its surface only, but occupies a more lateral or marginal 
position, the true diagnostic point being the relation or want 
of relation to the lacunae of the tonsil. Hence, if on the first 
inspection of the throat a membranous patch is seen covering 
the central portion of the convexity of one or both tonsils, and 
is limited to the tonsil, it may be regarded as very probable 
that the affection is follicular tonsillitis rather than diphthe- 
ria; while a membranous patch, however small and slight in 
appearance, which is seen on the marginal portion of the ton- 
sillar surface, and is evidently not in relation to the lacunal 
orifices as its source, should be carefully investigated. 

I have seen true diphtheritic membrane in its formative 
stage extending in slight streaks or spots across the tonsil. 
In those instances it has been easily to be seen that the 
streaks or spots did not emerge from the lacunal openings, 
and bore no relation to them, which is, in reality, the essen- 
tial point to be ascertained. 

The second method is syringing the throat with warm salt- 
water. In follicular tonsillitis this will cleanse the throat of 
much deceptive material. The membraniform covering of the 
tonsils will be in part at least broken up and washed away, 
showing its friable and superficial character, and its relation 
to the distended lacunal orifices. A prompt and accurate 
diagnosis is thus made practicable by a simple and readily 
available method in many cases in which it would otherwise 
be difficult or impossible. 

Like most other " ready methods " in diagnosis, those which 
I have now mentioned require to be used with due reserve and 
discretion, especially by inexperienced physicians and at times 
when diphtheria is epidemic. It cannot be denied that there 
are cases in which the most competent and experienced phy- 



132 diphtheria; its nature and treatment. 

sician must reserve his positive diagnosis for a day or two, 
and rare instances in which some doubt must remain even 
after the most careful consideration of all the attendant cir- 
cumstances. Yet the number of cases in which these tests 
when applied with accurate observation will fail is surpris- 
ingly small. This, I am sure, would be testified to by any one 
of at least twenty physicians who, during the past fifteen 
years as my assistants in the out-door visiting at Demilt Dis- 
pensary, have had frequent occasion to apply them, and some 
of whom are now well known in the profession. I have by 
the application of these methods in numerous cases, both in 
dispensary and private practice, been enabled to dispel the 
alarm occasioned by very formidable " diphtheritic " appear- 
ances by assuring the sufferers or their friends of their proba- 
bly innocent and transient character, and have been justified 
by the event. I have also been called in consultation in quite 
a number of cases of supposed diphtheria of some severity and 
danger, in which I have from the same considerations been 
enabled to assure the attending physicians that their patients 
would in all probability make a rapid and complete recovery, 
frankly stating to them the diagnostic grounds of my belief, 
and the prediction has in every instance been verified. 

I have under other circumstances personally known of not 
a few instances in which follicular tonsillitis has been mistaken 
for diphtheria by intelligent, conscientious and not inexperi- 
enced physicians. While this error is greatly to be depre- 
cated, not only on account of the needless alarm and incon- 
venience which it is liable to occasion, but still more because, 
as has unfortunately been but too widely illustrated in the 
literature of diphtheria, it renders in proportion to its fre- 
quency the teachings of therapeutical experience worthless or 
misleading, the opposite error of the mistaking of diphtheria 
in its mildest forms or its slight beginnings, for its benign 
counterfeit, may, in its immediate results at least, be even 
more disastrous. 



DIAGNOSIS. 133 

It hardly needs to be remarked that while the diagnosis is 
in any degree doubtful, the patient should be isolated, and the 
case treated as one of tonsillar diphtheria. 

The following case illustrates certain other elements of in- 
terest, which may sometimes attend this differential diagno- 
sis : In 1881 I saw, in consultation with two well-known physi- 
cians, the little daughter of another well-known physician of 
this city. She was suffering with a violent inflammation of 
the throat, accompanied with exudation upon the tonsils. 
There was also laryngeal stenosis, so grave that the necessity 
of tracheotomy was imminent. The question under anxious 
consideration was, Is the tonsillar disease follicular or diph- 
theritic ? After a careful examination, and with some hesita- 
tion on account of the gravity of the case, I concurred with 
one of the other consultants in the view that it was follicular, 
and on that diagnosis we based a favorable prognosis for the 
impending tracheotomy, believing that the laryngeal affection 
would prove to be catarrhal. The operation presently became 
necessary. It had a successful result, there being no evidence 
of the presence of false membrane in the larynx or trachea. 
At the same time the little sister of the patient was violently 
attacked as she had been, except that there was no laryngitis. 
The latter case proved unusually grave and persistent, with 
serious constitutional disturbance and depression, but yet 
progressed and terminated as follicular tonsillitis. It should 
be added that in the residence of these patients — a " first- 
class " one on Madison Avenue — there were found to be serious 
defects in the plumbing. This case is illustrative of the im- 
portance of an accurate diagnosis in cases requiring tracheo- 
tomy in order to give real value to statistics of the results of 
that operation in diphtheritic and non-diphtheritic cases. 



134 diphtheria; its nature and treatment. 



Explanation of the Following Plate. 

Figure 1 shows a usual and easily recognizable form of follicular 
tonsillitis in a woman thirty years of age on the third day of her illness. 
The characteristic location of the exudation and its evident relation to 
the lacunal orifices are here illustrated. 

Figure 2 depicts tonsillar diphtheria in a girl ten years of age on 
the third day of her illness. She was one of seven members of one 
family in the Willard Parker Hospital for Contagious Diseases who 
had been attacked nearly simultaneously, including the mother and 
five other children. In the mother and the four elder children the 
affection was limited to the tonsils and was mild in character. A child 
about three years of age had diphtheria of the tonsils, soft palate and 
nares, from which she recovered. The youngest — an infant — was in- 
tubated for laryngeal diphtheria, and died on the following day with 
the symptoms of the extension of the membranous affection into the 
bronchial tubes. 

Figure 3 represents diphtheria of the soft palate and tonsils in a 
female patient twenty-six years of age, on the sixth day of the disease. 
The uvula, which in this case is small and unaffected, is nearly con- 
cealed from view by the swelling of the adjacent parts. 

Figure 4 (from Dr. Lenox Brown's work on Diseases of the Throat) 
is a rhinoscopic view of the posterior nares in a fatal case of naso-pha- 
rnygeal diphtheria. 





Figure 2. 



Figure 4-. 





Figure I 



Figure 3. 



Lindner, Eddy & Clauss, Lith. N. Y. 



DIAGNOSIS. 135 

Scarlatina is another affection with which diphtheria is 
very liable to be confounded. This liability occurs usually in 
those cases of scarlatina in which the distinctive features of 
the disease, especially the eruption, are either absent or are so 
slight and ill-defined as to be overlooked, and in which pseudo- 
membranous exudation is present. 

The distinctive features indicative of scarlatina are in the 
earlier stage the following: the fever is usually higher in scar- 
latina, especially in the malignant form without eruption; 
vomiting, common to both, is especially characteristic of the 
first onset of scarlatina. The well-known appearances of the 
tongue in scarlatina are usually more or less typical. The 
appearance of the throat formerly described by me : as char- 
acteristic of scarlatina, — namely, a bright diffused or punctate 
redness extending from one or both tonsils along the faucial 
half-arches to the uvula, and shading off more or less gradu- 
ally on the soft-palate, is rarely altogether wanting. The 
diphtheroid form of scarlatinal angina, which is also charac- 
teristic, is described in the chapter on secondary diphtheria, to 
which the reader is referred. 

At a later period the well-known tendency of scarlatinal 
inflammation to extend into the nares and into the middle ear 
is a very suggestive diagnostic feature, the latter region being 
very rarely invaded by primary diphtheria. 

Albuminuria and nephritis are the more probably of a 
scarlatinal origin in proportion to the lateness of their occur- 
rence, and also to their presenting certain features; as the 
presence of blood in the urine, which is frequent iu scarlatinal 
and infrequent in diphtheritic albuminuria, and their being ac- 
companied by subcutaneous oedema, of which the same is true. 

The evidences of the invasion of the nasal passages by 
diphtheria have been described in the chapter on symptoms. 

^'Clinical Observations on the Early Stages of Scarlatina." Read 
before the New York Academy of Medicine. N. Y. Medical Record, 
March 23rd and 30th, 1878. 



136 diphtheria; its nature and treatment. 

When this occurrence is thus made probable, but false mem- 
brane is not visible on ordinary inspection/ the diagnosis may 
in some cases be readily completed by the use of the nasal 
speculum or the rhinoscopic mirror; but a universally availa- 
ble method is the syringing- of the nares, as will be described 
in the chapter on treatment. This procedure will first demon- 
strate the occlusion of the nasal passages, and, if persevered 
in, will usually dislodge and bring* away shreds or larger por- 
tions, of membrane. 

When the symptoms of croup are preceded or accompanied 
by the presence of false membrane in the pharynx or nares, 
the laryngeal affection is, as a rule, pseudo-membranous. In 
cases in which they are not thus accompanied it is sometimes 
difficult to decide whether it is membranous or catarrhal. 
Positive evidence that it is the former may in some cases be 
obtained by the aid of the laryngoscope, and in some others is 
afforded by the coughing up by the patient of shreds of mem- 
brane. When an attack of croup follows exposure to the con- 
tagion of diphtheria, or occurs during an epidemic of that dis- 
ease, it may be presumed to be membranous. Some children 
are by individual or family predisposition subject to attacks of 
catarrhal croup after taking cold. In such patients the recur- 
rence of that affection is under ordinary circumstances more 
probable than the occurrence of membranous croup, though 
the latter is of course not impossible. A sudden onset, especi- 
ally at night, is characteristic of spasmodic croup, and if it 
have not been preceded by symptoms of laryngitis warrants 
that diagnosis. Mere remissions in the symptoms, however, 
with sudden exacerbations, are by no means so conclusive, since 
a spasmodic element is sometimes very pronounced in the 
earlier stages both of catarrhal and membranous croup. The 
persistency and steady increase of serious croupal symptoms 
may be due either to membranous laryngitis or to severe 
catarrhal laryngitis. The former is the more usual cause in 
such grave cases, and is therefore the more probable one in 



DIAGNOSIS. 137 

any given case; yet in the absence of positive evidence of the 
existence of membrane the diagnosis can never be absolute, 
since some such cases have been found after tracheotomy or 
at the autopsy to be purely catarrhal. 

Reasons have elsewhere been given for the belief that there 
is a membranous croup which is not diphtheria, but yet that 
under ordinary circumstances the two affections are so liable 
to be complicated or confounded that the diagnosis of the 
former can rarely be a positive one. This diagnosis must re- 
late mainly to the following points: — Simple membranous 
croup is not traceable to the contagion or the endemic or epi- 
demic influence of diphtheria, but to non-specific causes which 
are usually meteorological; it occurs by marked preference in 
the colder seasons of the year and in exposed situations ; it is 
itself non-contagious; it is sporadic, or, if it occurs epidemic- 
ally, does so as the evident result of special meteorological 
conditions; it is entirely or mainly limited to the air-passages; 
it is an acute local inflammation attended with fever which 
never becomes adynamic; it is never attended with the symp- 
toms of diphtheritic or septic constitutional poisoning; it is 
fatal only by mechanical obstruction to respiration; it is never 
followed by paralysis. 

The presence of croupous bronchitis may be regarded as 
probable when, in the course of laryngotracheal diphtheria, 
there is a marked increase in temperature and in frequency 
of respiration, with the physical signs of bronchitis and 
broncho-pneumonia; but the diagnosis can never be positive 
except from the evidence afforded by the coughing up of mem- 
branous casts of the bronchial tubes. 

The unreliability of symptoms which point to the existence 
of oesophageal diphtheria has been referred to in the chapter 
on symptoms. Evidence afforded by the laryngoscope, or by 
the expectoration of membrane from that location, is the only 
basis of a positive diagnosis. Gastric or intestinal diphtheria 
can be positively recognized during life only from the vomit- 
ing or the voiding of its pseudo-membranous products. 



138 

When a paralysis with the characteristics which have been 
elsewhere described follows a recognized attack of diphtheria, 
there can be no question as to the diagnosis. In those cases 
in which the preceding- disease has been unrecognized, the 
nature of the paralysis is usually made plain by the fact that 
it affects the palate only or mainly, or that having first at- 
tacked that organ it has successively invaded other parts in 
an order and in a manner which, though subject to variations, 
are yet typical of diphtheritic paralysis. • A history of a pre- 
ceding sore throat or coryza can then usually be obtained. In 
rare cases the palate may not have been affected, and the 
paralysis when it presents itself to the physician may have 
become more or less general, a considerable time having 
elapsed since the attack of diphtheria. Even in such a case 
there are usually evident characteristics of diphtheritic paral- 
ysis in the history of its gradual progress from one part to 
another, one having wholly or partly recovered its strength 
as others have become weak, in the disturbances of vision and 
the strabismus, and even in the fact that when the palate is 
not at first affected, it is often attacked at a later period. 
Even when it most deviates from the usual order of occur- 
rences there is in its very capriciousness and irregularity, in 
its incompleteness, in the intermingling of sensory disturbances 
with motor paresis, a physiognomy which is recognizable from 
that of most other paralyses. Diphtheritic paralysis of the 
extremities may simulate locomotor ataxia in the incoordina- 
tion of movements and the loss of the knee-jerk, but it may 
usually be distinguished from that affection by its more rapid 
onset, by the greater muscular weakness and by the absence 
of the characteristic pains. It differs from simple paraplegia 
in its history, in the loss of the knee jerk and in its compara- 
tively short duration. In acute atrophic paralysis the change 
in electro-muscular contractility is usually much greater, and 
there is no disturbance of sensation. In hysterical paralysis 
the palate is never affected. 



CHAPTER IX. 

PROGNOSIS. 

Diphtheria has always been justly regarded as a most 
dangerous disease. In many recorded epidemics a large ma- 
jority of all cases have proved fatal. Even at the present 
time, and in spite of all our therapeutic progress, its general 
fatality continues to be very great. 

The proportion of deaths from diphtheria to reported cases 
of the disease in this city during the eight years, 1880 to 1887, 
inclusive, according to the returns of the Board of Health, is 
shown in the following figures, for which I am indebted to the 
courtesy of Dr. John T. Nagle : 



Year. 


No. of Cases. 


No. of Deaths. 


jrercema 
of Death 


1880 


3307 


1390 


42.03 


1881 


5272 


2249 


42.65 


1882 


3507 


1525 


43.48 


1883 


2906 


1009 


34.37 


1884 


2201 


1090 


49.47 


1885 


2920 


1325 


45.37 


1886 


3737' 


1727 


46.21 


1887 


5923 


2167 


36.58 



Average 42.62 

The statistics of the disease in Boston during the same 
period, which have been kindly given me by Dr. John H. 
McCollom, City Physician, are somewhat more favorable: 



uo 



Year. 


No. of Cases. 


No. of Deaths. 


.rercenia 
of Deatl 


1880 


1715 


588 


34.2 


1881 


1680 


601 


35.7 


1882 


1386 


458 


33.04 


1883 


1415 


445 


31.4 


1884 


1212 


345 


28.46 


1885 


1263 


334 


26.44 


1886 


1188 


329 


27.69 


1887 


1049 


316 


30.12 



Average 30.88 

It is justly objected to the conclusions from such statistics 
that not all the cases of diphtheria are reported ; but in view 
of what has been remarked in the preceding" chapter as to the 
unquestionable frequency of errors in diagnosis, it is very 
probable that the deficiency referred to has been at least com- 
pensated for by the reporting of milder forms of disease as 
diphtheria. In 23 of the 1049 cases reported as diphtheria in 
Boston in 1887, the error in diagnosis was so palpable as to be 
noted by the Sanitary Inspectors, who can hardly be supposed 
to have been hypercritical, under the heading, " Mistake in the 
report made by physicians." x 

In some statistics in which no error is possible, the terrible 
fatality of the disease is even more strikingly indicated. Thus, 
in three hundred and nineteen cases in the wards of the Royal 
Charite Hospital in Berlin, reported by Henoch 2 in 1885, two 
hundred and eight, or 65.5 per cent.,, were fatal. According to 
the statistics of the Hospital Trousseau, Paris, for the year 
1883, 3 of 606 cases of diphtheria treated, 391 died, or 64.5 per 
cent. On the other hand, medical literature abounds in reports 
of large numbers of cases of diphtheria, some of which will be 

1 " Report of the Board of Health of the City of Boston for 1887," p. 25. 

2 Charite" Annalen, vol. x., p. 490. 

3 Archives of Paediatrics, 1884, p. 321, from Rev. Mens, des Mai. de 
l'Enf., February, 1884. 



PROGNOSIS. 141 

subsequently referred to, in which under very various modes 
of treatment recovery has been the invariable result or nearly 
so. The possible sources of error in such enumerations are 
elsewhere considered. 

The estimate is probably within bounds that at least thirty 
per cent, of all cases of genuine diphtheria terminate fatally, 
though, of course, in many groups of cases the mortality is 
very much less. 

In so far as the prognosis in diphtheria is based on general 
conditions, it is less favorable in that which is epidemic than 
in that which is endemic or sporadic. It must also vary ac- 
cording to the general character of the prevailing epidemic, 
since some epidemics are much more severe and fatal than 
others. It is less favorable at the outset or the height of an 
epidemic than during its decline. It is less favorable in the 
country than in cities; in the colder seasons of the year than 
in summer ; in insanitary conditions than in opposite ones. It 
is also in the same degree of severity of the disease much less 
favorable in the cases of children under three or four 3'ears of 
age than of older patients. 

The prognosis in a case of diphtheria must at its onset be 
a guarded one, since the subsequent extent and character of 
the disease can never be positively predicted from the symp- 
toms at that stage; yet severity in the early local and general 
manifestations of the disease is of comparatively unfavorable 
prognostic import, while mildness is correspondingly favorable. 

Since the dangers to be chiefly apprehended in diphtheria 
are two, namely, pseudo-membranous obstruction of the air- 
passages and constitutional poisoning, the prognosis must be 
based on the greater or less tendency 01 the disease in each, 
particular case to produce one or the other or both of these 
results. 

The commencement of the disease in the larynx, or the 
subsequent occurrence of the symptoms of croup, is of most 
unfavorable portent. When no symptom of the extension of 



142 diphtheria; its nature and treatment. 

the disease thither has appeared by the third day from the 
attack, the chances of escaping it may be regarded as fair, 
and they improve by a rapidly increasing ratio with each 
subsequent day's immunity, until the sixth or seventh, when 
they may be regarded as very favorable. The prognosis in 
laryngeal diphtheria is especially unfavorable when the symp 
toms of that affection are accompanied with those of constitu- 
tional poisoning, or when, either before or after tracheotomy 
or intubation, there are evidences of the presence of bronchi 
tis, tracheal and bronchial diphtheria, broncho-pneumonia, 
lobar pneumonia or pulmonary oedema. 

In diphtheria in which the larynx is not involved the prog- 
nosis is unfavorable in direct proportion to the gravity of the 
local affection, as manifested in the intensity of the inflamma- 
tion, and the extent and more especially the depth of the 
pseudo-membranous formation and its occurrence in locations 
which are most favorable to toxic absorption. 

If the fever which was high at the outset continues high 
for some days, or if, having been moderate, it becomes persist- 
ently high, its significance is unfavorable, because it denotes 
that the disease is severe and progressive or that some serious 
complication exists. 

Adenitis is of unfavorable significance in proportion to its 
amount and the rapidity of its development. 

The symptoms which have been elsewhere described as es- 
pecially indicative of constitutional diphtheritic poisoning, 
such as pallor, prostration, somnolence, anorexia, etc., are of 
bad prognostic import in proportion to their gravity, the 
earliness and rapidity of their development and their persist- 
ency in spite of appropriate treatment. 

Vomiting, when it begins and continues at a later stage of 
the disease, in connection with marked anorexia, and is not 
merely the result of inappropriate medication, stimulation or 
feeding, is an evidence of profound constitutional poisoning 
and is a bad omen. 



PEOGNOSIS. 143 

Marked weakness of the pulse and indistinctness of the 
heart-sounds with excessive rapidity or slowness, especially 
when accompanied with irregularity, are premonitory or indic- 
ative of heart-failure. Endocarditis is also a very unfavora- 
ble complication. 

The importance of albuminuria varies according- to its 
gravity and other circumstances which have been stated in 
the chapter on symptoms. 

Delirium, when it is merely the accompaniment of high 
fever in the earlier stages of the disease, is not necessarily of 
the most serious import, hut when it occurs in connection with 
symptoms of grave septic and urgemic poisoning, and with 
other evidences of resulting meningeal or cerebral implication, 
is too often the precursor of a final coma. 

Purpura hsemorrhagica occurring in the course of diphthe- 
ria is usually of fatal import. 

Gangrenous diphtheria, although always a grave form of 
disease, is not, under suitable treatment, the hopeless one which 
some authorities have pronounced it. In quite a number of 
cases which have been included in my experience the majority 
have recovered, 

Nasal diphtheria, which has been considered by some good 
authorities as almost necessarily fatal, may under suitable 
treatment be regarded much more hopefully, as it undoubtedly 
admits of cure in the majority of all cases. The danger which 
it involves is proportionate to the amount and persistency of the 
pseudo-membranous affection of the nasal passages, and to the 
amount of constitutional poisoning which has already taken 
place. This danger is markedly increased by the occurrence 
of epistaxis, which, when serious and persistent is a most un- 
favorable complication. 

When the various local and general manifestations of the 
disease which have now been referred to take place with that 
impetuous and overwhelming rapidity which constitute its 
malignant form, the prognosis is grave indeed. 



14A diphtheria; its nature and treatment. 

In the mild grade of diphtheritic paralysis, limited mainly 
to the soft palate, which is seen in the large majority of cases, 
the prognosis is favorable both as to a brief duration of the 
attack and its involving no serious danger to life. In other 
cases the prognosis in respect to both these circumstances 
varies according to the severity of the attack, the earliness 
with which it follows the primary disease, and the parts which 
it affects. When the initial paralysis of the palate proves to 
be unusually severe and persistent, it becomes probable that 
the limbs will also be affected, and when the paresis in them 
is especially grave, it is likely that the upper extremities will 
not escape. Under these circumstances the duration of the 
attack instead of from two to six weeks will be as many 
months. As a general though not an invariable rule the de- 
gree of paralysis is in some direct proportion to the closeness 
of its sequence to the primary disease. 

Danger to life from diphtheritic paralysis is proportionate 
to the degree of its interference with heart action, respiration 
or deglutition. Definite symptoms of cardiac paralysis occur- 
ring within a week or two after the onset of diphtheria are 
too often of fatal import. The danger from paralysis of the 
respiratory muscles is greatest when both the intercostals 
and the diaphragm are affected. Its degree is in proportion 
to that of the dyspnoea and of the accumulation of mucus in 
the bronchial tubes. In serious paralysis of the pharynx and 
the larynx there are the dangers of inanition from the diffi- 
culty of swallowing food and the repugnance to attempting it, 
and of suffocation or pneumonia from portions of food entering 
the air-passages. 



CHAPTER X. 

PROPHYLAXIS. 

The prophylaxis of diphtheria must consist in preventing, 
removing*, or avoiding- as far as possible its general and special 
causes. These have been referred to in the chapter on etiol- 
ogy. 

It follows that in selecting a residence all possible care 
should be taken to avoid the conditions which predispose to 
the disease, such as damp situations, unsusceptible of drain- 
age, the vicinity of stagnant and polluted water, etc. The 
greatest attention should be paid to preventing the contami- 
nation of drinking-water. Too many shade-trees about a house 
are undesirable, and every pains should be taken to secure an 
ample supply of sunlight in the dwelling-rooms as well as 
thorough ventilation, and cleanliness in and about the habita- 
tion. The habitual use by children of abundant and whole- 
some food is of great importance. Since many attacks of 
diphtheria follow catching cold the greatest attention should 
be paid to the suitable dressing of children, the prevention of 
damp feet, etc. Careful attention must also be paid to the 
ventilation, warming and general sanitary condition of the 
school-houses which they attend. 

The securing of the enactment of proper sanitary regula- 
tions in towns and villages and their faithful enforcement by 
the authorities should be regarded as a most important duty 
by every citizen. The removal of the conditions which favor 
disease, such as overcrowding, filth, etc., from the tenement- 
houses and hovels of the poor, might prevent many an epi- 
10 



146 diphtheria; its nature and treatment. 

demic which from those sources invades and devastates the 
homes of the more fortunate classes. 

During- the prevalence of an epidemic, especial attention 
should be paid to everything* which relates to the health of 
children. Their throats should be frequently inspected. Their 
colds and catarrhs should receive prompt treatment. It 
should be remembered that decaying teeth and coated tongues 
may furnish a nidus for disease-germs. If there is a tendency 
to relaxed conditions of the mucous membranes the mouth 
and throat may be frequently washed, gargled or sprayed, or 
the nasal passages syringed or sprayed with some mild anti- 
septic and astringent liquid such as will be mentioned in the 
next chapter. Depressed conditions of the general health 
should be promptly corrected by the use of suitable tonics, 
especially iron. At such times, also, the greatest vigilance 
should be used by teachers, parents and the public authorities 
to prevent the introduction of the disease into schools or to 
ensure its prompt recognition should that occur. 

When a case of the disease occurs in a family, the patient 
should at once be strictly isolated — preferably in a room at 
the top of the house, which should be capable of free ventila- 
tion and exposed to direct sunlight. All unnecessary furni- 
ture, especially hangings and upholstery, should first be re- 
moved from it. Should there be reason to suspect unfavorable 
endemic conditions, the well children should, if practicable, 
be sent away until the danger of infection is over. In any 
case they should be kept under the vigilant supervision of a 
physician. Their throats should be inspected twice daily, and 
the preventive local and general measures just referred to 
should be promptly employed when indicated. I have, in 
many cases of children who had been exposed to the contagion 
of diphtheria, or were continuously exposed to it, directed that 
the tincture of iron mixture or that of iron and the chlorate of 
potassa, of which the formulae will be given in the next chap- 
ter, should be administered every two or three hours, and 



PROPHYLAXIS. 147 

have had reason to think that the result has been advan- 
tageous. 

Nurses who attend upon the sick should be kept isolated 
from the children of the household. 

The danger of the emanation of diphtheritic poison from 
the sick and the consequent infection of others will be greatly 
diminished by the employment of the local antiseptic treat- 
ment of the disease, which will be described in the next chap- 
ter, and of thorough measures of cleanliness, ventilation, etc. 
The records of 201 dispensary cases, including many very 
severe ones, thus treated by me, 1 in which little or no separa- 
tion of the sick from the well was practicable, show that 2 
occurred together or consecutively in the same family in eigh- 
teen instances, 3 in five instances, and 6 in one instance, while 
144 were solitary cases subsequently to the commencement of 
antiseptic treatment, although not a few of them had been 
preceded by other cases under other treatment. 

In case of death from the disease the corpse should be 
placed in an air-tight casket, the burial take place promptly 
and the funeral be strictly private. 

The following are from the " Instructions for Disinfection " 
issued by the Health Department of this city in 1888: 

I. Disinfectants to be Employed. 

1. Roll Sulphur (brimstone) for fumigation. 

2. Sulphate of Zinc and Common Salt dissolved together in 
the proportion of four ounces of the former and two ounces of 
the latter in a gallon of water; for clothing, bed-linen, etc. 

3. Sulphate of Iron (copperas) dissolved in water in the 
proportion of one and one half pounds to the gallon; for soil, 
sewers, etc. 

4. Corrosive Sublimate Solution. Made by dissolving bi- 
chloride of mercury in the proportion of eight grains to the 

1 See New York Medical Record, April 9th, 1887, p. 399. 



148 

pint of water. To the discharges of a sick person should be 
added an equal quantity of the solution. 

II. How to Use Disinfectants. 

1. The clothing", towels, etc., should, on removal from the 
patient, and before they are taken from the room, be placed in 
a pail or tub of the zinc solution, boiling hot. All discharges 
should be received in vessels containing the corrosive subli- 
mate or the copperas solution. When that is impracticable 
they should be covered immediately with the solution, All 
vessels used about the patient should be cleansed with the 
solution. 

2. For fumigation the rooms to be disinfected must be 
vacated, and closed as tightly as possible, stopping up chim- 
neys, ventilators, etc. Place the sulphur in iron pans sup- 
ported upon bricks placed in wash-tubs containing a little 
water ; set it on fire by means of hot coals or with the aid of a 
little alcohol poured over it. Allow the room to remain 
closed for twenty-four hours; then open all windows and air 
thoroughly. 

Heavy clothing, bedding and other articles which cannot 
be treated with the zinc solution should be hung in the room 
during the fumigation, their surfaces thoroughly exposed. 
Care should be taken to have woolen and cotton goods free 
from moisture, or the sulphur fumes will injure them. 
Pockets should be turned inside out. Afterwards the articles 
should be hung in the open air, and thoroughly beaten and 
shaken. 

Pillows, beds, upholstered furniture, etc., should be cut open, 
the contents spread out and fumigated. Carpets are best 
fumigated on the floor, but should afterwards be removed to 
the open air and thoroughly beaten. 

For fumigation at least three pounds of sulphur should be 
used for every thousand cubic feet. 

3. Body and Bed Clothing, etc. — It is best to burn all arti- 









PROPHYLAXIS. 149 

cles which have been in contact with persons sick with conta- 
gious or infectious diseases. Articles too valuable to be de- 
stroyed should be treated as follows : 

(a) Cotton, linen, flannels, etc., should be treated with the 
boiling-hot zinc solution. Introduce piece by piece to secure 
thorough wetting, and boil for at least half an hour. 

(6) Heavy clothing, etc., should be treated as described 
under the directions for fumigation. 

4. Water-closets, privies, sewers, etc., should be frequently 
and liberally treated with copperas solution. 

At a meeting of the Michigan State Medical Society x the 
secretary demonstrated in a tabulated statement accompanied 
with a graphic chart the extent to which isolation and disin- 
fection had reduced the number of cases of diphtheria and the 
number of deaths therefrom in the various outbreaks reported 
by local health-officers during the year 1886. In 102 outbreaks 
in which there was a neglect of one or both of these measures, 
the average number of cases to the outbreak was a little over 
16, and the average number of deaths 3.23; while in 116 out- 
breaks in which both were enforced the average number of 
cases was 2.86, and that of deaths 0.66. In other words these 
simple precautions reduced the number of cases occurring 
during the year by 1545, and the number of deaths by 298. 



New York Medical Journal, May 21, 1887, p. 580. 



CHAPTER XI. 

TREATMENT. 

General Indications. 

The factors which are to be dealt with in the treatment of 
diphtheria are, as has already been seen: 

1. A parasite which is implanted on or in the mucous mem- 
brane or other affected surface, and there produces the poison 
which causes the disease. 

2. A specific inflammation which is excited thereby, and 
which has the two following- results : 

(a) The reproduction and local dissemination of the poison, 
and 

(b) The production of a false membrane which, though 
itself inert, does harm in two ways, namely, by shutting- in the 
poison and preventing- its removal and thus favoring- its ab- 
sorption, and also in certain situations by interfering- mechan- 
ically with vital functions, especially respiration. 

3. The absorption of the poison or poisons into the circula- 
tion, and the production thereby of a g-eneral disease which is 
characterized by a tendency to adynamia and the occurrence 
of various org-anic lesions. 

The principal g-eneral indications which have to be met in 
the treatment of diphtheria, are, therefore, the following- : 

1. To destroy, remove, or limit the action of the invading- 
poison. Measures for this purpose include the employment of 
a great variety of ag-ents and processes for local disinfection 
and for the removal of the false membrane and also of inter- 
nal medication to promote the same objects. 



TREATMENT. 151 

2. To subdue or limit the inflammation. Measures for this 
purpose are both local and general. 

3. To obviate the occlusion of the air-passages by false 
membrane. Measures for this purpose are surgical and me- 
chanical. 

4. To promote the elimination and counteract the effects of 
poison which may have been absorbed. 

5. To economize and sustain the vital forces in their com- 
bat with the disease. 

6. To avert or combat the morbid effects of the disease 
upon particular organs, and other special dangers which may 
in any case arise during its course. 

General Principles of Treatment. 

The practicability and the relative importance of each of 
these indications, and the choice of means for its accomplish- 
ment, vary in different cases according to many circumstances, 
among which are the type, the stage, and the localization of 
the disease and the age and constitution of the patient. Wo 
merely routine method, therefore, can be indiscriminately 
employed, but the treatment must be intelligently adapted to 
the circumstances in each particular case. 

The fulfilment of the first and most obvious of the indica- 
tions just enumerated is in practice opposed by difficulties 
which are often grave and sometimes insuperable, arising* 
from the inaccessible location of the affection in many cases, 
the opposition made to our efforts by young children, and the 
fact that the parasite which causes the disease, except in its 
mildest forms and earliest stages, lies not merely on the 
affected surfaces, but within their more superficial tissues and 
in inaccessible recesses, while in not a few instances complica- 
ting septic organisms have become widely distributed through 
the system. In such cases successful efforts at local disinfec- 
tion must often be limited to diminishing in some degree the 
growth and vital activity of the pathogenic organisms rather 



152 DIPHTHERIA; ITS NATURE AND TREATMENT. 

than their eradication, to softening* and thinning- the false 
membranes rather than their complete destruction, and to 
diluting- and washing- away some portion only of the chemical 
poison of the disease, and thus diminishing-, thoug-h not en- 
tirely preventing-, its absorption. When the disease in its 
grave forms is once fully established, it cannot, in the ma- 
jority of cases, be cut short. Its "cure" must often con- 
sist in checking- to the utmost possible degree its dangerous 
tendencies and sustaining- the strength of the patient until the 
malady ceases by self -limitation. 

The fact that diphtheritic inflammation is characterized 
by an extreme liability to be aggravated by any extraneous 
irritation, and that such ag-gravation of the inflammation in- 
evitably involves the increase and intensification of the disease, 
forbids the use of all harsh measures that are not absolutely 
necessary, and requires the utmost possible gentleness in all 
manipulations and medication. 

The fact that the tendency of the disease is to asthenia re- 
quires the careful avoidance of all unnecessarily weakening, 
harassing or fatiguing measures. 

It follows that, especially in the treatment of young chil- 
dren, who constitute a large proportion of our patients in this 
disease, it is of the greatest importance to avoid all medication 
which is so unpleasant to the taste or so painful to the sensi- 
tive throat as to arouse repugnance and opposition, and thus 
occasion a series of exhausting struggles. Not a little treat- 
ment which has been excellent in intention and sound in prin- 
ciple, has been rendered futile or even worse than no treat- 
ment at all by having precisely this effect. 

The application of this principle makes it necessary to omit 
some methods of treatment in the cases of young children, 
which are practicable and very valuable in those of older 
patients. 

On the other hand, it is important to remember that the 
insidious and dangerous character of diphtheria demands the 



TREATMENT, 153 

utmost promptitude and decision in combating* it. Measures 
which are essentially unpleasant but necessary must be inflex- 
ibly carried out. Everything- depends in many cases on the 
earliness with which efficient measures are employed. 

While the theory of the treatment of diphtheria consists in 
the application of certain broad and easily understood princi- 
ples, its successful practice requires the closest attention to 
details — many of them apparently trivial. This in all severe 
cases includes the necessity of very frequent visits on the part 
of the physician, and the careful instruction of parents and 
nurses. » 

The successful treatment of diphtheria not only demands 
a careful adaptation of measures to each particular case, but 
often especially requires a patient persistency in the use of 
well-selected ones. Under the best treatment there must 
often be a succession of anxious days in which little or no pos- 
itively curative impression seems to be made upon the mal- 
ady. Impatience, indecision, and changes of method without 
definite reason, are but too liable in the battle with this dis- 
ease, as in other conflicts, to invite defeat. 

The Results of Treatment. 

The test of the value of therapeutical measures is their 
results. Yet an accurate estimate of those results in the 
treatment of diphtheria is extremely difficult. This difficulty 
arises mainly from two causes : 

1. The great differences in inherent tendency to a favora- 
ble or a fatal issue in different cases of diphtheria according- 
to their type (as benign, severe or malignant), their localiza- 
tion (as laryngeal, nasal or pharyngeal), according as they are 
sporadic or epidemic, and according to the widely varying 
character of different epidemics. The records of mortality 
from the disease under the same or similar modes of treat- 
ment vary from this cause between the most remote extremes. 

2. The confusing character of such records is greatly in- 



154 diphtheria; its nature and treatment. 

creased by the frequency of errors in diagnosis. Dr. L. E. Holt * 
well says, " Our journals are continually filled with new spe- 
cifics, accompanied with an enumeration of cases in which they 
have been successful. When detailed reports of cases are 
given, it is evident from a critical examination of them that 
the great number of them are not cases of diphtheria at all, 
while the universality of the successes claimed by others is a 
sufficient proof of the worthlessness of their observations. It 
must be evident to any one who attempts to keep up with the 
literature of the subject, that before any great advances can 
be made in the treatment of diphtheria we must insist on 
greater exactness in its diagnosis." 

It may be conducive to a just estimate of the value of re- 
ports of therapeutical results in this disease to consider for a 
moment what results from treatment can rationally be ex- 
pected. All cases of true diphtheria may be divided into three 
classes, namely (1), those which would recover without any 
medical treatment; (2), those which will terminate fatally 
under any treatment at present known, and (3), those the 
issue of which depends on the treatment employed. Any at- 
tempt to fix the proportion of these three classes must of 
course in the absence of data be in a large degree conjectural. 
I shall venture in this sense to estimate the first class at forty- 
five per cent, of all cases; the second at ten per cent., and the 
third again at forty-five per cent., though this last percentage 
is practically diminished and the second increased by the fact 
that in all large numbers of cases a considerable proportion 
come under the care of the physician too late for treatment to 
be effective. It is evident, even without assuming the accu- 
racy of these estimates, that the distribution of these three 
classes, especially in small series of cases, may be so different 
that apparently very favorable or very unfavorable results of 
treatment may be largely accidental. 

By the law of averages, the liability to this source of error 
1 Trans, of the Med. Soc. of the State of New York, 1886, p. 553. 



TEEATMENT. 155 

is greatly diminished in large numbers of cases, but even such 
statistics are worthless if there is room for doubt as to the 
correctness of the diagnosis. It follows that all statistical 
contributions to the therapeutical literature of diphtheria, in 
order to be of authoritative value, should not only accurately 
describe the methods of treatment employed, but should also 
be accompanied with such descriptions of the cases referred 
to as will place it beyond doubt, not only that they were gen- 
uine cases of diphtheria, but also to what forms and types of 
the disease they belonged. By such painstaking methods 
only can the requisite data be furnished for a reliable system 
of therapeutics in this disease. 

The Modes of Employing Remedies. 

1. Internal Administration. — This is not only the usual 
method of employing remedies for constitutional effect, but is 
also one of the most important modes of their local applica- 
tion. For the latter purpose it has the advantages of sim- 
plicity and easy availability, and important and obvious lim- 
itations as to the class of medicinal agents to which it is 
adapted, and the surfaces which it reaches. 

2. Gargling. — This method is not only unavailable in the 
cases of young children, but even in those of older patients its 
frequent employment in diphtheria is unpleasant and fatigu- 
ing. It is moreover in many cases inefficient, from the reme- 
dies so employed not freely reaching the posterior part of the 
pharynx. It is therefore in most cases inferior to the two 
methods next to be mentioned. 

3. Spraying. — This method has the advantages of being 
gentle and unirritating, and not very fatiguing, and that by it 
remedies may be applied in a more direct, evenly diffused and 
continuous manner to the oral and pharyngeal surfaces than 
by most other methods, and may even by the aid of the in- 
spired air be made to reach the rima glottidis and the vocal 
cords. It is important to remember that if the spray is too 



156 diphtheria; its nature and treatment. 

coarse and too forcibly driven its effect may be irritating-. 
This method is advantageous only when the fluids so used 
reach the affected surfaces as spray. It is efficient in the 
throat only when the mouth is widely opened or the tongue is 
depressed. Its frequent use, therefore, requires the voluntary 
cooperation of the patient, and is unfortunately not practicable 
in most cases of children under three years of age. For rea- 
sons which will be referred to in speaking of the treatment of 
nasal diphtheria, it is in most cases less available in that con- 
dition than the method next to be mentioned. 

4. Irrigation. — This may be effected by means of a syringe, 
of the piston, hand-ball or fountain variety. The first is usually 
preferable. It is a very important and valuable method of 
cleansing affected surfaces and applying suitable remedies to 
them. It is, however, important that it be employed with the 
utmost gentleness which is consistent with its efficiency, as 
otherwise its effect may be irritating and injurious. Its spe- 
cial applicability is to the nasal passages, and to the throat in 
the cases of children too young to be sprayed. 

5. Vaporization and Inhalation. — This method has obvi- 
ous advantages for the introduction of certain substances into 
the system for constitutional effect, and also for bringing them 
into direct contact with the otherwise inaccessible mucous 
membranes of the air-passages. Its most important limita- 
tion is the danger of its interference with the purity or respi- 
rability of the air. 

6. Insufflation. — The application of certain substances to 
directly accessible surfaces in the form of powder has obvious 
advantages. Substances so applied are liable to be irritating 
in direct proportion to their insolubility and the coarseness of 
the powder. 

7. Application by means of a brush, pencil, or swab. — 
This method has the advantages of precision and accurate 
limitation. It is therefore specially adapted to the application 
of concentrated and irritating substances. Its use is contra- 






TREATMENT. 157 

indicated for other than directly accessible surfaces, and, as a 
general rule, in the cases of young- children. 

Various details in these modes of employing- remedies will 
be more appropriately spoken of elsewhere. 

Caustics. 

Aretseus advocated the employment of caustics in the fol- 
lowing words: "Utile fuerit, igitur, partem affectam igne 
adurere, sed factu temerarium utpote in tarn angusto faucium 
loco; quam ob rem medicamentis igni simillibus utendum 
est." 1 

Bretonnea a obtained " favorable results " and "cures" by 
the local application of concentrated hydrochloric acid, either 
diluted with three parts of honey, or, later and preferably, 
pure, the object and effect being to "substitute another in- 
flammation in order to arrest that which is specific." Recog- 
nizing the danger of harsh applications, Bretonneau limited 
its employment as follows : " When the disease is not arrested 
by two energetic applications made at an interval of twenty- 
four hours it would be imprudent not to abandon it." 

The employment of nitrate of silver having been introduced 
by Dr. Mackenzie, 2 of Glasgow, Bretonneau, in his fifth 
memoir, stated that he had found it less painful and more 
efficacious than hydrochloric acid. He employed the solid 
stick and a sponge moistened with a strong solution. He 
stated that when the treatment is commenced on the first day 
of the disease (two applications being made daily) " a radical 
cure may be obtained in forty-eight hours," but that " every 
hour and every day the necessity of a more active and pro- 
longed treatment goes on increasing in melancholy propor- 
tion." 

That the practice of Bretonneau was attended with very 

1 It would be useful to burn the affected part with fire, but a rash 
practice on account of the narrowness of space in the fauces ; for which 
reason medicaments similar to fire must be employed. 

2 Med and Surg. Journ. , vol. xxiii. , p. 294. 



158 diphtheria; its nature and treatment. 

favorable results is evident even from his modest statements. 
For instance, he mentions that on one occasion when he was 
summoned by the Minister of War to the Ecole Militaire, on 
account of an epidemic of malignant angina which had shown 
an alarmingly fatal character, he treated sixty of the pupils 
who were suffering from the disease at a more or less ad- 
vanced stage with a favorable result in every case. 

In laryngeal diphtheria the moistened sponge was applied 
to the glottis, the epiglottis being held up by a spatula. The 
result was that in some cases the false membrane was expec- 
torated and the necessity for tracheotomy obviated, a cure 
resulting on the fifth or sixth day. Similar results in his own 
practice and in that of his fellow practitioners were reported 
by Mackenzie, of Glasgow, and also by Gendron, 1 Girouard, 2 
Bouchut, 3 Velpeau, 4 Geddings, 5 and many others. Trousseau 
practiced and recommended cauterization with the substances 
just referred to, and also with cupric sulphate in saturated 
solution, and the acid nitrate of mercury. Other caustics 
which have been employed in the treatment of diphtheria are 
nitric, sulphuric, chromic and strong carbolic acid and caustic 
soda and potash. With the exception of carbolic acid, which 
may sometimes be advantageously used either pure or diluted 
with equal parts of glycerine or water, their action is both 
painful and dangerous. 

The use of the actual cautery during an epidemic of diph- 
theria in 1828 by Dr. Bonsergent, who thrust a red-hot iron 
into the diphtheritic throats of children, is described by Trous- 
seau, 6 who " witnessed some successful results " of this danger- 
ous procedure. Trousseau employed it himself, but only in 
cutaneous and vulvar or oral diphtheria. 

1 Journ. compl. du Diction, des Sc. M6d., t. xxiii., p. 346. 

2 Journ. G6n. de M6d., t. ciii., p. 305. 

3 " Traite" pratique des Malad. des Nouveaux Ne"s," etc., 1852. 
4 Gaz. MeU, 1830, p. 11. 

5 Amer. Journ. of the Med. Sc., vol. xxiv. 

6 Clinical Medicine, vol. ii. 



TREATMENT. 159 

The use of caustics was in some cases attended with deplor- 
able accidents and fatal results, which called forth protests 
against their employment from Archambault-Reverdy 1 and 
many subsequent writers. Moreover, the spread of the belief 
in the primarily constitutional rather than local nature of 
diphtheria contributed not a little to their gradual and almost 
universal disuse. The use of nitrate of silver has, however, 
always had its adherents. Dr. T. J. Hutton 2 of Fergus Falls, 
Minnesota, for instance, applies lunar caustic in solution in the 
strength of from twenty to fifty grains to the fluid drachm of 
water with a camel's hair brush once or twice daily so long as 
membrane continues to form. He states that in 209 cases 
thus treated by him only twelve have died. 

Among the caustic agents which have been referred to, the 
nitrate of silver is least open to certain objections and has 
special limitations. Its action is comparatively superficial. 
It is one of the least irritating of caustics. Locally it causes 
greater contraction of the vessels than other metals. (Brun- 
ton.) It combines with albumen and destroys or imprisons 
parasitic fungi which are exposed to its action. Its utility as 
a caustic in diphtheria is therefore limited to the earlier stages 
and the more superficial forms of the disease. 

The use of the actual cautery has been revived in the form 
of the galvano-cautery, by Dr. Tedeschi 3 and by Dr. Bloebaum. 4 
This treatment was first employed by the latter in many cases 
of diphtheria in young pigeons and subsequently in a number 
of cases of human diphtheria. Besides gargles of ice-water no 
other treatment was employed. Prof. Henoch, 5 of Berlin, also 
employed thjs method in a grave case of diphtheria with a 
favorable result. 

The use of the galvano-cautery is described as painless. 

1 Journ. Univ. des. Sc. M6d., t. Mi., p. 257. 

2 New York Med. Rec, April 9, 1887, p. 417. 

3 Ri vista Venet., Nov., 1885. 

4 Verhandl. d. Cong. f. innere Med., Wiesbaden, 1886, V. 432. 
fa Therapeutic Gazette, 1886, p. 603. 



160 diphtheria; its nature and treatment. 

At its mere touch the false membrane rolls up and falls off. 
It is not reformed nor does the diphtheritic process extend. 
The fever and the glandular swelling rapidly subside. The 
slough which it causes comes away in eight to fourteen days, 
leaving a healthy ulcer. 

Even after making all due allowance for mistakes in diag- 
nosis and other sources of error, the evidence which has now 
been referred to seems to be conclusive to the effect that the 
application of caustics in the early stage of diphtheria has in 
not a few instances cut short the disease, preventing its local 
development and its constitutional manifestations. This fact 
is of great interest and importance as adding confirmation to 
the view of the primarily local nature of diphtheria which has 
been maintained in this work, arid is full of suggestiveness as 
to the direction which should be given to future efforts to per- 
fect the therapeutics of the disease, especially in its early 
stages. It cannot be denied that the application of powerful 
caustics in diphtheria is open to grave objections and is at 
best subject to great and important limitations. The theory 
of their use is the destruction of the specific character of the 
inflammation. It is evident, however, that if they fail to com- 
pletely accomplish this object, the inflamed and necrosed tis- 
sues caused by their use must become an especially favorable 
soil for the occupation of the diphtheritic virus, and the result 
is liable to be an aggravation of the disease. Since the utility 
of cauterization is mainly restricted to the early stage of the 
disease, and to cases in which it is definitely limited to easily 
accessible locations, its employment is under any circum- 
stances practically excluded in a large proportion of the worst 
cases with which we have to deal. Since, moreover, it is liable 
to be more or less painful, is in its very nature calculated to 
inspire dread, is difficult or impossible of safe execution in the 
cases of young children, and, moreover, when employed inju- 
diciously or clumsily is liable to produce disastrous results, it 
is not probable that the verdict of the profession, which has 






TREATMENT. 161 

consigned it to almost complete disuse, will ever be to any 
great extent reversed. Other and less hazardous means of 
accomplishing the same ends will continue to he sought for. 

Astringents. 

Astringents are especially valuable in the presence of g*reat 
swelling of the tonsils and uvula, relaxed, ulcerated or hsemor- 
rhagic conditions of the mucous membrane and profuse secre- 
tions. 

The astringents which have been principally employed in 
the treatment of diphtheria are alum, tannin, the liquor ferri 
subsulphatis and the chloride of iron. 

The use of alum and of tannin (in the form of powdered 
nut-galls) was recommended by Aretaeus. The former was 
used by Bretonneau, and both by Trousseau. Powdered alum 
has been much used by being blown into the throat through a 
tube or by means of an insufflator. Trousseau employed in 
this way from one to two grammes at each application, which 
he caused to be repeated from four to ten times in the twenty- 
four hours. He advised that these be alternated with insuffla- 
tions of four or five grains of tannin. Alum mixed with honey 
and the glycerine of tannin have also been applied with a 
camel's hair pencil. Alum in solution in water or in vinegar 
and water has been beneficially employed by gargling and 
irrigation, and tannin in a five per cent, watery solution as 
spray. 

The liquor ferri subsulphatis (Monsel's solution) has been 

found by many to be an especially valuable local astringent. 

It may be applied either pure or diluted with an equal part of 

water or glycerine by means of a camel's hair pencil or a fine 

soft swab to easily accessible diphtheritic patches once or 

twice daily. Its effects are thus graphically described by Dr. 

C. C. P. Clark, 1 who has for twenty years used no other local 

application : The salt is in no way a caustic, nor, so far as he 

1 New York Med. Journ., June 7, 1884. 
11 



162 diphtheria; its nature and treatment. 

knows, a poison to bacilli, " but it is a mighty astringent, and 
seems to operate by puckering the life out of the diphtheritic 
deposit and sucking or squeezing the bad juice out of the living 
parts adjacent. The patch or patches may indeed reappear 
again and again, but always with less density and diminished 
rankness of look/' 

Dr. J. Solis-Cohen 1 has found chloride of iron applied locally 
by firm and gentle pressure with a brush, or, preferably, cot- 
ton -wad — the most serviceable agent he has used in topical 
treatment. "The drug has an astringent and antiseptic 
action, assists the detachment of false membrane, and appar- 
ently prevents the spread of the infection." 

From the occasional topical use of both of the drugs last 
referred to, either pure or diluted with half the quantity of 
glycerine, I can testify to their favorable action in suitable 
cases. 

Agents for the Destruction of False Membrane. 

False membrane may be removed by the use of escharotics 
(which has already been spoken of), by avulsion and by sol- 
vents. From considerations which have been already referred 
to as to the evil of harsh and irritating measures in the treat- 
ment of diphtheria, it is now a well-recognized principle that 
as a general rule the forcible removal of diphtheritic mem- 
brane is a procedure which is to be mentioned only to be con- 
demned. When a portion of a membranous patch has become 
detached and loosened, while a deeper portion still continues 
adherent, there is great temptation to the inexperienced physi- 
cian to hasten the cure by its removal. But not only should 
this temptation be resisted, but especial gentleness in the giv- 
ing of food and medicines should then be practiced, since its 
premature detachment is very liable to be followed by an 
intensification of the inflammation, increased absorption of 
poison and a new formation of membrane. 
1 Medical News, June 23, 1888. 



TREATMENT. 163 

Loosened portions of still adherent membranous patches 
may, when accessible, be advantageously trimmed away with 
scissors. 

The removal of membrane by scraping-, rubbing- or picking 
it away with forceps has been employed by some in the early 
stage of the disease as a preliminary to the local application 
of an antiseptic, as will subsequently be more particularly re- 
ferred to. The capabilities and limitations of such methods 
are so nearly identical with those of the use of caustics that 
they need not be further referred to. 

Solvents of False Membrane. 

Warm vapor has long been much employed for softening, 
disintegrating and promoting the detachment of false mem- 
brane. Dr. M. J. Oertel, 1 advocates the general use of this 
agent in the treatment of diphtheria, and that the inhalations 
be practiced as often and as long as possible — for fifteen min- 
utes every half -hour on the first and second day, allowing only 
three or four hours for sleep. 

The softening and loosening of the false membrane is 
effected not merely by the action of the vapor upon it, but 
also by the increased secretion of mucus and the promotion of 
suppuration beneath it. 

There can be no doubt of the tendency of warm vapor to pro- 
duce all of these effects, and that it is a valuable therapeuti- 
cal agent whenever the false membrane lies loosely and super- 
ficially upon the mucous membrane, as it usually does in the 
larynx, the trachea and the bronchial tubes. In the pharynx, 
where the false membrane is commonly more deeply imbedded 
and more firmly attached, the employment of this mode of 
treatment is open to serious objections. Then the time re- 
quired for the softening and loosening effect of the steam is 
necessarily much greater, and meanwhile not only is the false 
membrane softened, but the healthy tissue also is macerated 
1 Ziemssen's Cyclopaedia, vol. i. 



164 diphtheria; its nature and treatment. 

and relaxed — a condition which, while it promotes suppura- 
tion, probably favors also the penetration of pathogenic fungi 
and the absorption of septic poison. The tendency of the use 
of steam to produce this effect was pointed out by Dr. A. 
Jacobi in 1874. Its actual observation in a number of cases 
has long ago led me to regard the valuable application of this 
therapeutical method as mainly limited to the treatment of 
croup. 

The effect of steam upon false membranes may be increased 
by making it the vehicle of other solvents. This is often done 
by slaking lime in the croup-kettle or other receptacle, or by 
placing lime-water or other solvent solution in the cup of the 
steam-atomizer. It should be remembered that the vapor 
produced by boiling lime-water is simply — steam. 

Medicinal agents which are capable of dissolving false 
membrane without exerting any injurious effect upon the liv- 
ing tissues have long been eagerly sought for, and some of 
them hold an important place in the therapeutics of diphtheria. 

The principal substances which have been thus employed 
are lactic acid, lime-water and other alkalies, pepsin, trypsin 
and papayotin. 

The inferiority in solvent power of lactic acid to lime-water 
or trypsin has been shown in the following experiment by Dr. 
F. E. Waxham. 2 Three similar pieces of false membrane 
were sprayed at half -hour intervals, one with a solution of 
trypsin, the second with officinal lime-water, the third with a 
ten per cent, solution of lactic acid. The first was dissolved in 
two hours; the second, in three hours; the third was softened, 
but not completely disintegrated, in three and one half hours. 

In rapidity of action as a solvent of membrane, lime-water 
is probably inferior to trypsin. This inferiority is illustrated 
in the following experiment by Dr. H. D. Chapin : 3 Two pieces 

1 The American Journal of Obstetrics, February, 1875. 

2 Chicago Med. Journ. and Examiner, June, 1885. 

3 New York Med. Record, March 7, 1885, p. 257. 



TREATMENT. 165 

of very thick firm membrane in situ on two portions of the 
trachea, which had been bisected post-mortem, were sprayed 
every fifteen minutes, the one with a solution of trypsin, the 
other with lime-water, to which one per cent, of liquor potassas 
had been added. In two and one half hours the former was 
completely diffluent, except the under side of its thickest por- 
tion, which retained some membranous structure; the latter 
was softened but its integrity was preserved. 

Lime-water in therapeutical use where rapid solvent effect 
is required is inadequate. It may be sprayed day after day 
upon diphtheritic membrane in the throat with the effect only 
of dissolving away the thinner portions and superficially soft- 
ening and thinning the thicker portions. Its principal utility 
as a solvent in the case of thick and dense membrane there- 
fore consists in rendering it more permeable by antiseptic 
agents through osmotic action, and thus giving important 
aid in disinfection. While it is not available against the more 
severe forms of laryngeal diphtheria, it is of great value in 
many cases in which the membrane is not very thick. In 
quite a number of such cases I have seen it keep the affection 
within such moderate bounds that recovery has taken place 
without the necessity of an operation. 

It has been theoretically urged against the efficiency of 
lime-water spray as a solvent of false membrane in the throat 
that it must at once be rendered inert by the carbonic acid in 
the expired breath. That this supposition is erroneous I have 
shown by experiments with pieces of litmus paper held in the 
back part of the pharyx. 1 The same fact has also been shown 
by Dr. J. Lewis Smith, 2 who found by experiment that mixing 
lime-water with one-fourth its quantity of carbonic-acid water 
" did not seem to impair materially the solvent power of the 
lime." 

In estimating the therapeutical value of lime-water in diph- 

1 See New York Med. Record, 1880, xvii., p. 383. 
*Op. cit., p. 322. 



166 diphtheria; its nature and treatment. 

theria it is important to remember that, aside from its solvent 
action upon false membrane, its other effects, even when it is 
used continuously, are in no way injurious, but are in every 
respect eminently calculated to be beneficial. It is a mild as- 
tringent, a mild antiseptic (destroying- bacterial spores in ten 
days (Koch), a local sedative and antiphlogistic. Its very 
valuable sedative and corrective action in the irritable stom- 
ach is well known. Hence its utility is much more likely to 
be underestimated than overrated. From much experience in 
its use I regard it as entitled to a place in the very front rank 
of remedial agents in the treatment of diphtheria. Lime- 
water may be employed by internal administration, by irriga- 
tion, and as spray, either pure or in combination with other 
antiseptics. 

Other alkalies, such as liquor potassae , or bicarbonate of 
soda, have been added to lime-water for the purpose of increas- 
ing its solvent power. Such addition of one per cent, of the 
former is recommended by Dr. J. Lewis Smith; and bicarbon- 
ate of soda has been employed in solution and by insufflation. 1 
As either of these alkalies is known to be slightly irritating to 
inflamed mucous membranes, their availability for very fre- 
quent and continued application must be inferior to that of 
lime-water, though they may be very valuable in emergencies 
requiring rapid solvent effect. 

Pepsin acts efficiently only in an acid solution — one con- 
taining from one to two tenths of one per cent, of hydrochloric 
acid being the most favorable. The fluids of the mouth and 
throat are usually either alkaline or neutral. This has been 
regarded as an important drawback to the availability of 
pepsin as a solvent of false membrane in situ, and it has of 
late been to a great extent superseded in general use for this 
purpose by trypsin and papayotin. 

In a paper recently read before the Section on Paediatrics 

1 Dr. E. M. Moore, Transactions of the N. Y. State Medical Associa- 
tion, 1885. 



TREATMENT. 167 

of the New York Academy of Medicine x Prof. R. H. Chitten- 
den made the following- important statements: Even making" 
allowance for the disadvantage just referred to, pepsin must 
at present be regarded as a more reliable solvent of false 
membrane than trypsin — not that trypsin is a less efficient 
solvent, but that, owing- to the great difficulty of isolating- it, 
no trypsin has yet been produced which is nearly as powerful 
as the best pepsins which are now in the market, thoug-h the 
trypsin produced by Fairchild has considerable efficiency. 
The difficulty arising- from the alkalinity of the fluids in the 
mouth and throat may be obviated in the following- man- 
ner: The amount of hydrochloric acid in the pepsin solution 
should be a little in excess of that required for normal diges- 
tion — say about four tenths of one per cent., in order to 
allow for its neutralization and dilution. The solution em- 
ployed should be a concentrated one, and the applications 
should be very frequent. A suitable mode of employing- it 
would therefore be by the following- formula : 

^ Scale pepsin, .... 3j — 3 ss. 

Acidi hydrochloric!, . . . ttuj. 

Glycerini, . . * . . . 3j 

Aquae dest., . . . . 3 vij. 

M. 
To be applied every five, ten, or fifteen minutes by brush or 
atomizer. 

There is abundant testimony to the quite rapid solvent 
action of trypsin upon diphtheritic membrane. Dr. H. D. 
Chapin 2 describes a case in which extreme symptoms of 
tracheo-bronchial diphtheria which gradually supervened after 
tracheotomy were mitigated within half an hour and entirely 
dispelled in a few hours as the result of frequent spraying 
through the cannula with a solution of trypsin. The child hav- 
ing died of blood-poisoning, the autopsy showed thick mem- 
brane lining the larynx and trachea down to the spot that was 
1 Medical News, 1889, vol. liv., p. 173. ' 2 Loc. cit 



168 diphtheria; its nature and treatment. 

first reached by the spray; but below that point there were 
on the intensely injected mucous membrane only disintegrated 
shreds of false membrane, which condition continued as far 
as to the bronchial tubes of the second order. 

Since the first effect of the application of a pepsin-acid 
solution is to cause the swelling- up of false membrane, while 
trypsin produces its direct disintegration, the latter should be 
preferred for spraying- into the larynx in diphtheritic croup. 

Trypsin acts best in an alkaline medium, and its solvent 
action is undoubtedly aided by that of the alkali. The follow- 
ing- is a suitable mixture, which should be freshly prepared 
when it is to be used: 

Ijt Trypsin, 3 ss. 

Sodae bicarbonatis, .... gr. x. 

Glycerini, 3 ss. 

Aquae destillatse, . . . . ad § j. 

To make a smooth mixture the trypsin should be rubbed 
down with the water added little by little. When it is used 
with a brush a little should be poured out in a saucer for the 
purpose, in order to avoid returning- the brush into the solu- 
tion after using it. When it is used in spray the best method 
is to fit the atomizing- instrument to a small narrow bottle or 
a test-tube, into which a drachm or two of the mixture may 
be poured. This may now be immersed in a glass of hot water 
until its contents are warm, and then the spray may be ap- 
plied. Trypsin acts more rapidly when at a temperature 
slightly above that of the body. The remainder of the mixt- 
ure should be kept in a well-stopped bottle. These directions 
accompany the trypsin of Fairchild, which has been referred 
to as being especially efficient. Trypsin should be applied 
very frequently — every ten or fifteen minutes being not too 
often. 

Papayotin is efficient in an alkaline or a neutral medium, 
and less so when the reaction is acid. 

Neither of the solvents last referred to has any specific 



TREATMENT. 169 

action upon false membrane, but they are simply ferments 
which act with great power in dissolving- coagulated albumen. 

Papayotin has usually been employed in a five per cent, 
solution in water, sometimes with the addition of an antisep- 
tic, as a small proportion of salicylic acid, applied hourly or 
half -hourly, by brush, irrigation or spray. Dr. A. Jacobi x rec- 
ommends its use in the proportions, papayotin one part, 
glycerine and water, each two to four parts, applied hourly. 
Rossbach 2 says that in order to be most effective the solution 
should be applied to the parts every five minutes, a few drops 
being- placed upon the tong-ue or in the nose. Very young 
children may be allowed to suck a napkin which is moistened 
with a sweetened solution, or it may be inhaled after atomiza- 
tion. By this plan the membrane often becomes dissolved in 
two or three hours. He believes that if this substance is 
properly used it will obviate the necessity for tracheotomy. 
There is a general concurrence of testimony in respect to both 
papayotin and trypsin, that though they do in some cases at 
least, especially in the early stage of diphtheria, exert a favor- 
able and limiting effect upon its course, yet they are not spe- 
cifics for the disease, that they are without curative effect upon 
its infiltrated form, and that the constitutional disease when 
once established may go on to a fatal termination in spite of 
the dissolution of the false membrane. 

There is also a general agreement that both of these agents 
are innocuous to mucous membranes. 

The following is a suitable formula for the use of papayo- 
tin : 

Jjfc Papayotin, . ... gr. xxv. 

Glycerini, 3 ss. 

Aquae destillatae, . . . .ad fj. 
M. 

The powerful tendency of jaborandi and pilocarpine to in- 

1 Therapeutic Gazette, 1886, 145. 

2 Deutsches Arch. f. Klin. Med., Bd. XXXVI., H. 3 and 4. 



170 diphtheria; its nature and treatment. 

crease the secretion of mucous membranes has led to their 
administration for the purpose of thus causing 1 the maceration 
of diphtheritic membranes, and hastening* their detachment. 
Its successful use in many cases has been reported by G. 
Guttmann * and others. Lax 2 recommends the following for- 
mula 

^ Pilocarpini hydrochlorat., . gr. iij. 

Pepsinae, gr. j.. 

Aquae dest., . . . . n. § ij 3 iss. 

Acidi hydrochlorici, . . gtt. ij. 

M. 
Dose, a small or large spoonful to be given according- to 
age and effect. 

Since pilocarpine is liable to cause depression of the heart's 
action, collapse, nausea and vomiting and albuminuria, and 
since the copious salivation and perspiration which it produces 
are necessarily weakening, its continued use for a long enough 
time to fufill the above-mentioned indication is now generally 
condemned as dangerous. 

ANTISEPTICS. 
Cleanliness. 

In the " Instructions for Disinfection " by the New York 
Board of Health, from which quotation has been made in the 
preceding chapter, it is well remarked that " disinfectants " {i.e. 
chemical agents) " should not be relied upon to correct condi- 
tions due to dirt, decomposition, defective ventilation and 
neglect." This principle, so true in reference to the disinfec- 
tion of apartments, premises, etc., is equally applicable to the 
disinfection of the living body in the treatment of diphtheria. 
The thorough cleansing by suitable means of all surfaces 
affected by the disease, or liable to become so, in the mouth, the 
throat, the nasal passages and elsewhere, is of far greater 

Berlin. Klin. Wochenschr., 1880, No. 40, p. 569. 
2 Journal de Medicine de Paris, Feb. 6, 1887. 



TKEATMENT. 171 

practical importance in the whole number of cases than the 
mere administration of antiseptic drugs, and the use of the 
latter, though important, can in no case atone for neglect or 
inefficiency in the former. 

The Resistance of the Organism. 

Bacteria and their spores, which invade the blood and tis- 
sues, are attacked, digested, and destroyed by the cells, 1 or in 
case of their overwhelming number and vigor destroy the 
cells. When the body is weak or exhausted by hunger or 
fatigue the power of thus destroying invading organisms is 
proportionally small. From this fact it appears that nutritive 
and sustaining measures in the treatment of infectious diseases 
may properly be regarded as measures of disinfection, that 
the use of antiseptic drugs which may be weakening to the 
patient should be carefully avoided, and that an agent which 
merely diminishes in a slight degree the vital activity of bac- 
teria may turn the scale in the conflict between them and the 
cells, provided that it is less poisonous to the latter than to 
the former. 

The Salts of Mercury. 

Among bactericidal drugs, the one which is efficient in the 
greatest dilution is the bichloride of mercury. According to 
the experiments of Koch 2 it hinders the development of an- 
thrax bacilli (a comparatively resistant organism) in the 
strength of yrnriinnr m the nutrient solution, prevents it in the 
strength of tswtsj kills the spores of the bacilli in ten minutes 
in the strength of 20 ooo ? and with one wetting in the strength 
of — i 

KJL 10 00* 

Other salts of mercury, as the sulphate, the nitrate, the 
cyanide and the iodides are also very efficient bactericides, 
though in a somewhat less degree than the bichloride. 

1 Metschnikoff, Virch. Archiv. vol. xcvi., p. 177, and xcvii., p. 502, 
and Fodor, Arch. f. Hygiene, Bd. 134, p. 149. 

2 Mittheilungen aus dem k. Gresundheitsante, vol. i. 



172 DIPHTHERIA; ITS NATURE AND TREATMENT. 

For prompt and certain local antiseptic effect corrosive 
sublimate is applied in a solution of the strength of from -j-^ 
to -g^g- by brush, swab or atomizer. 

In order that this effect shall be produced it is necessary 
that the bacteria and their spores be actually wetted with the 
solution in its full strength or nearly so. If the affected sur- 
faces are covered with profuse and viscid secretions, as is often 
the case, they should first be cleansed by spraying- or irrigation, 
and afterwards dried bj^ touching* them lightly with absorbent 
cotton. 

A still greater obstacle is usually presented in the false 
membrane. If this be exceptionally thin, superficial, and loose 
of texture, the solution may penetrate to its under surface 
with no very great dilution ; but in proportion as it is thicker 
and denser this becomes impossible. 

But even if the false membrane have previously been re- 
moved, the fact remains that the fungi of the disease, so far as 
we have means of judging 1 , do not lie merely on the surface of 
the mucous membrane or the denuded tissues, except at a very 
early stage of the disease or in its more superficial forms, but 
also beneath the epithelial layers or even in still deeper 
structures. 

It follows from these considerations that the eradication of 
diphtheria in its really deeper and graver forms, except at a 
very early stage, even by the local use of this most poAverful 
of bactericides must often be opposed by insuperable obsta- 
cles, and this conclusion is confirmed by experience. For exam- 
ple, W. W. Cheyne * has employed the following treatment : 
He first removes as much of the membrane as is possible with 
forceps, and then applies to the denuded surface a watery solu- 
tion of bichloride (one in five hundred) with a brush every two 
hours, especial attention being directed to the margin of the 
affected region. In the intervals a gargle of bichloride in the 
strength of one two-thousandth is used. This treatment has 
1 British Medical Journal, March 5, 1887, p. 504. 



TREATMENT. 173 

" quickly and completely arrested " the disease in several adult 
cases which were " taken early/' but in the case of children 
" the results are not so good." 

Corrosive sublimate is also employed in higher dilution — 
that of B oVo> ToVo or T"oi wo — f° r local antiseptic effect by fre- 
quent internal administration, gargling-, irrigation and atomi- 
zation. That a solution of one grain of corrosive sublimate in 
the pint of water is a safe and useful antiseptic wash in many 
cases of diphtheria cannot be doubted; yet even in that dilu- 
tion, the effect of its frequent application to diphtheritically 
inflamed surfaces has seemed to me less beneficial and more 
liable to be irritating than that of other substances yet to be 
mentioned. It should also be borne in mind that in spraying 
the throat and irrigating the nasal passages of children, even 
with a solution of this strength, caution is needed that a dan- 
gerous quantity of the poisonous salt be not swallowed. 

In view of the enormous dilution in which corrosive subli- 
mate diminishes the vital activity of bacteria, the idea that it 
may be introduced into the circulation in sufficient quantity, 
even making allowance for its constant elimination, to have 
some influence in the struggle between the living body and its 
pathogenic invaders is probably not altogether chimerical. 
This view is favored by the results of the experiments of Cash, 1 
who found that the continued administration of minute doses 
of sublimate to animals rendered them capable of resisting 
the effects of the subsequent inoculation of anthrax. 

There is reason to believe that the salts of mercury, inter- 
nally administered, have a tendency to oppose the occurrence 
of fibrinous exudation in the air-passages, and to promote its 
detachment when formed. Reports of the successful treat- 
ment of membranous croup with calomel have been too nu- 
merous in the medical literature of this and other countries to 
be easily explained by the theory of mere coincidence. Though 

1 Proceedings of the Physiological Society, Dec. 12, 1885. Journal of 
Physiology, vol. vii. 



174 diphtheria; its nature and treatment. 

that treatment, having- been found in many cases disappoint- 
ing* in its result and injurious in its effects, was long ago gen- 
erally abandoned, yet testimony to its efficacy continues occa- 
sionally to appear. Heroic dosage is an element in its em- 
ployment by some, as for instance in the successful treatment 
of three children suffering from laryngeal diphtheria, twenty 
grains of calomel was given at first, followed by ten grains 
hourly — seven hundred and twenty grains having been taken 
by a child twenty-eight months old in three days ! x 

It is a relief to learn that diphtheria has been successfully 
treated by the use of two to five gTains of calomel every one 
to three hours until the dejections are frequent and green, 
then continuing the same doses at lengthened intervals so as 
to keep up the catharsis, 2 and even by doses of one sixth of a 
grain every hour, increased in the presence of threatening 
laryngeal symptoms to one third of a grain every hour, and 
then to one grain every two hours for five hours, in a patient 
eighteen months old, 3 and in thirty-six consecutive cases by 
the following- method : The diseased part is first wetted with 
a two to five per cent, solution of common salt — then two to 
four tenths of a grain of calomel are blown over it twice daily, 
the throat being in the mean time gargled every two hours 
with the salt solution. A portion of the calomel becomes bi- 
chloride, and the remainder passes into the stomach and pro- 
duces free catharsis. 4 

There is a concurrence of testimony from many judicious 
practitioners as to the benefit which may be derived from pur- 
gative doses of calomel at the early stage of diphtheria, es- 
pecially in cases in which there is high fever with deficient 
secretions and marked nervous disturbance — a benefit which 

] Dr. J. P. Klingensmith, of Blairsville, Pa., New York Medical 
Record, July 12, 1884, p. 36. 

2 Dr. W. H. Daly, of Pittsburg, New York Med. Record, June 12, 
1886, p. 692. 

8 Dr. Geo. B. Fowler, New York Med. Record, Nov. 19, 1887, p. 647. 

4 Kotzuski, Jahrb. f. Kinderh., xxi., p. 272. 



TREATMENT. 175 

I have observed in many cases, and which was referred to 
in my first publication (1876). It may be given in a single dose 
of from two to ten grains, or in doses of a fraction of a grain 
(one tenth to one half) repeated frequently (from every twenty 
minutes to every two hours) until its characteristic purgative 
effect is produced. 

At the present time mercury is most generally employed 
in the treatment of diphtheria in the form of the bichloride. 
Its use in large doses (one quarter to one-half grain or more 
daily) has been advocated in this country by Dr. W. Pepper, 1 
(and hence widely known as the "Pepper treatment") and 
subsequently by Dr. A. Jacobi 2 and by many others. 

Of its efficacy in diphtheritic croup, Dr. Jacobi 3 says, " I 
have never since 1863 seen so many cases of tracheotomy get- 
ting well as between 1882 and 1886, when the bichloride was 

constantly used as mentioned I can name a dozen of 

New York physicians, some of whom have often performed 
tracheotomy, who can confirm the above statements from 
their own observations. Nor does the opinion of those differ 
who constantly perform intubation. I know that O'Dwyer, 
Dillon Brown and Huber have come to the same conclusions." 
The doses referred to by Dr. Jacobi are "from one sixtieth to 
one fortieth of a grain and sometimes more," given hourly in 
a tablespoonful of water, milk or other compatible fluid. 

To the valuable efficacy of the bichloride of mercury (as, 
indeed, of most other prominent remedies used in the treat- 
ment of diphtheria) there is in recent literature a striking 
array of testimony, of which the following examples are given 
mainly to illustrate different modes of employing it : 

Dr. E. C. Carter, Assistant Surgeon United States Army, 4 

1 Transactions of the American Medical Association, 1881. 

2 " The Medicinal, mainly Mercurial, Treatment of Pseudo-Membra- 
nous Croup, 11 New York Medical Record, 1884, vol. 25, p. 573; and "A 
System of Medicine by American Authors, 1 ' Phila., 1885, p. 705. 

3 " Therapeutics of Diphtheria, " Medical News, June 16, 1888, p. 663. 

4 Medical News, Nov. 27, 1886, p. 593. 



176 diphtheria; its nature and treatment. 

in an epidemic of diphtheria near Fort Thomas, Arizona, hav- 
ing- treated the first eleven cases with other remedies with 
four fatal results, gave bichloride in thirty-four subsequent 
cases in doses varying from one sixty-second to one twenty- 
fourth of a grain with unvarying success. That they were 
genuine cases of diphtheria seems to be attested by the fact 
stated that twelve of the patients who recovered had paraly- 
sis. 

Dr. P. Werner, 1 having previously lost between sixty and 
seventy per cent, of ninety cases, employed bichloride treat- 
ment in the succeeding- seventeen — mostly severe ones — with 
only two fatal results, and those in cases seen only a few 
hours before death. He gave doses of -^o to ^ of a grain (ac- 
cording to age), well diluted in water, every twenty or thirty 
minutes while the patients were awake, so that one quarter 
of a grain was taken daily by young children, one half by 
older ones, and three quarters by adults. 

J. Stumpf, 2 having in the early part of an epidemic lost 
twenty-two out of twenty -nine cases, employed in the succeed- 
ing thirty-one cases the bichloride of mercury only, with fav- 
orable result in all but two. He administered in spray one 
fluid drachm of a solution of the strength of ^gVo* 2"oW or toVo 
(according to age) hourly for five times, then every two hours 
for five times, and subsequently every three hours. 

Dr. E. L. Oatman, 3 of Nyack, N. Y., having previously lost 
ten out of twenty-three cases under treatment with iron in 
large doses and free stimulation, has, since the addition of 
local treatment with the bichloride, lost only one out of thirty- 
four cases. Dr. Oatman prepares a number of swabs by 
firmly twisting absorbent cotton around the end of a small 
stick. Every hour one of these is dipped into a solution of the 
bichloride (two grains to the pint) and passed into the throat 

*St. Petersburg Med. Wochenschr., 1886, r. F. III., p. 81. 
2 Muenchener Med. Wochenschr., 1887, p. 219. 
8 New York Med. Record, April 23, 1887, p. 465. 



TREATMENT. 177 

until it touches the posterior wall of the pharynx and then in- 
stantly withdrawn and burnt, no swab being- used a second 
time. More or less of the membrane always adheres to the 
swab. This procedure is repeated hourly until the disease be- 
gins to subside, which it usually does in forty-eight hours. If 
the nares are affected, the nose is syringed. 

The biniodide of mercury is regarded as especially effica- 
cious by some. It is employed by Dr. C. G. Rothe, 1 of Alten- 
burg, in the following formula : 

^ Hydrargyri biniodidi, . . gr. £. 

Potassii iodidi, .... gr. iij — gr. ivss. 

Aquae destillatas, . . . fl. § j 3 vij. 

Tincturee aconiti, . tt[ xv. 

M. 

A teaspoonful is given hourly to a child under three years 
of age. Dr. Rothe has thus treated successfully forty cases. 

Extraordinarily favorable results from the use of the cya- 
nide of mercury are reported by Dr. J. Bree 2 and by Dr. H. 
Sellden, 3 a Swedish provincial medical officer. The latter re- 
ports fourteen hundred cases treated by himself and his col- 
leagues, with a total mortality of sixty-nine, or 4.9 per cent. 
The formula he recommends is as follows : Cyanide of mercury, 
two centigrammes (gr. ^) ; tincture of aconite, two grammes 
(tt[xxx.); honey, fifty grammes (|j. 3 ivss.); distilled water 
one hundred and fifty grammes ( ? iv. 3 vss.). Mix and give a 
teaspoonful every fifteen, thirty or sixty minutes, according to 
the patient's age. A gargle of the cyanide in peppermint 
water in the strength of tovoTo i s a l so to be used frequently. 

Inunction of mercurial ointment has also been much em- 
ployed in the treatment of diphtheria. For its more rapid 



1 Journ. de Med., June 5, 1887. 

2 "Behandlung der Diphtherie mit Quecksilbercyan," Dissertation, 
Berlin, 1886. 

3 London Lancet, March 24, 1888, p. 591. 
12 



178 DIPHTHERIA; ITS NATURE AND TREATMENT. 

absorption the oleate is recommended by Dr. A. Jacobi * — ten 
or twelve drops to be rubbed into the skin every hour or two. 
The hypodermic injection of corrosive sublimate is recom- 
mended by the same author — four or five drops of a one-half 
or one per cent, solution to be so used from four to six times a 
day or more. Dr. F. P. Henry 2 states that the hypodermatic 
injection of corrosive sublimate is so painful that few will con- 
sent to its repetition, and prefers the bicyanide of mercury, 
since it is compatible with cocaine, which the former is not. 
He has found its employment in many cases by the following* 
formula comparatively painless : 

J£ Hydrarg. bicyanid., .... gr. ij. 
Cocain. hydrochlorat., . . . gr. iv. 

Aquae destillat., fl. § ss. 

M. 
Fifteen minims to be injected beneath the skin in the case 
of an adult. 

Mercury by fumigation has been used in the treatment of 
diphtheritic croup with remarkable success by Dr. J. Corbin, 3 
of Brooklyn. The child is placed in a crib under a tent pre- 
pared with barrel-hoops and blankets. Calomel is volatilized 
in the tent by heat, from forty to sixty grains being used in 
the case of a child eight or ten years of age. The lamp should 
be powerful enough to volatilize a drachm of calomel in one 
minute in order to avoid overheating the air in the tent. The 
child is kept under the canopy for twenty minutes, when the 
blanket is removed. This is repeated every two or three 
hours during the first day. After that period the cough is 
usually loosened, and the intervals between the fumigations 
are lengthened, but they should be at once resumed if the 
cough tightens. In some cases two or three fumigations daily 



J A System of Practical Medicine by American Authors, vol. i., p. 
705. 

2 Medical News, Nov. 3, 1888. 

3 New York Medical Journal, March 10, 1888, p. 261. 



TEEATMENT. 179 

have been continued for over a week. The aphonia may not 
disappear for a week or more, but that need excite no alarm. 
This treatment is not a substitute for tracheotomy or intuba- 
tion. 

Including- sixteen cases thus treated by himself, and four- 
teen by three other physicians, Dr. Corbin reports thirty 
cases, of which twenty-five, or about 84 per cent., recovered. 
In one of the fatal cases the treatment was abandoned by the 
family. In none of the other four did death result from ob- 
struction of respiration, but from the effects of toxaemia. 

The valuable action of mercury in the treatment of diph- 
theria, like that of most other remedies, is greatest when it is 
employed at an early stage of the disease. Then it has a ten- 
dency (in some cases at least) to limit the extension and mod- 
erate the intensity of the affection, and thus to diminish the 
subsequent constitutional poisoning-. But when the septic 
condition is once established it has not the power to arrest it, 
but if excessively or too long- used is very liable to aggra- 
vate it. 

In the internal administration of the salts of mercury it is 
most important to remember that these valuable therapeuti- 
cal ag-ents, when used beyond certain limits as to frequency, 
quantity and continuance, are dang-erous irritant and depress- 
ing- poisons; that this action of them must be especially dele- 
terious in a disease which is in itself so depressing- as diph- 
theria, and is particularly liable to be overlooked from being- 
attributed to the disease. 

In a judicious and timely protest ag-ainst the abuse of mer- 
curials in the treatment of diphtheria, Dr. J. E. Winters * 
says, " I know that as the result of the inconsiderate use of 
mercurials in the treatment of diphtheria, physicians are often 
called upon to treat the consequences of their want of cau- 
tion ; while they have blindly ascribed the rapidly progressive 



'"Diphtheria and its Management," New York Medical Record, 
Dec. 5, 1885, p. 617. 



180 diphtheria; its nature and treatment. 

anaemia, prostration, marasmus and death to the disease 
alone. . . . 

"I have unequivocal and direct evidence of the injurious 
effects of bichloride of mercury from two intelligent physicians 
who have had diphtheria, and who both experienced the de- 
pressing* effect of the drug-. They told me that they felt de- 
pressed as soon as the mercurial begun to have an appreciable 
action on the intestinal tract, and that there was a feeling of 
nausea and sinking even preceding this. I may add that after 
the discontinuance of the bichloride both patients felt within 
three hours the strengthening effect of the tincture of iron in 
full doses given hourly/' 

Carbolic Acid. 

Carbolic acid is a far less powerful bactericide than corro- 
sive sublimate. An aqueous solution of it in a strength of 
yoViy hinders the growth of anthrax bacilli: -^ prevents it; 
j^q to 2^-n prevents the growth of other bacteria; a five per 
cent, solution requires more than twenty -four hours to kill the 
spores of anthrax bacilli, though a one per cent, solution de- 
stroj's the bacilli themselves in ten minutes. Its use in full 
strength or with slight dilution as a caustic has already been 
referred to (page 158). 

Carbolic acid has great utility in the local treatment of 
diphtheria, since in suitable dilution it is not only an efficient 
antiseptic bat also has a valuable sedative and antiphlogistic 
action. Dr. T. M. Prudden * has shown that a solution of car- 
bolic acid of the strength of T -gVrr> locally applied under condi- 
tions in which inflammatory changes commonly occur, modi- 
fies those. changes by preventing any considerable emigration 
or locomotion of white blood-cells. 

Salicylic Acid. 
Salicylic acid is an efficient antiseptic. It hinders the 
growth of bacteria in a solution of the strength of y£o^> P re_ 
1 American Journal of the Medical Sciences. Jan., 1881, p. 82. 



TREATMENT. 181 

vents it in that of -rgVo"? an( i kills bacteria in that of gV Suc- 
cessful results have been claimed from its use in powder by 
insufflation and by brushing it over the parts affected. 1 The 
following- formula for its use is recommended by M. Ory : 2 

I£ Acidi salicylici, . . . gr. v. 

Glycerini, . . . . t . fl. 3 iij. 

Aquae lauro-cerasi, . fU xvi. 

Infus. eucalypti, . . . . fl. 3 iijss. 
M. 

To be applied by brush every hour by day and every two 
or three hours at night. It is said to hasten the disappearance 
of false membrane. 

Salicylic acid is more irritating to inflamed surfaces than 
carbolic acid. According to the statistics of Schuler, 3 in 41 
cases treated with chlorate of potassium there were 6 deaths; 
in 23 cases treated with carbolic acid there was 1 death; in 
15 cases treated with salicylic acid there were 7 deaths. 

Dr. A. d'Espine 4 has ascertained by experiments that sali- 
cylic acid, even in a solution of 1 : 2000, is an excellent parasiti- 
cide of the bacillus of diphtheria. Its harmlessness in this 
dilution makes it a very available application by irrigations, 
which should be repeated hourly. The especial utility of this 
employment of it would obviously be in the early stage of the 
disease and as a prophylactic. 

Chinoline. 

Chinoline is a powerful antiseptic, and in strong concen- 
trations is sharply caustic. Its local effect in the treatment 
of diphtheria has been favorably reported upon by Dr. O. 



1 Noeldechen of Pforta, Deutsche Med. Zeitung, Nos. 33-36, 1886. 

2 Revue Gren. de Clinique et de Therapeutique, July 5, 1888. 

3 Berlin Klin. Woch., 40. 

4 Medical News, 1889, 54, p. 187, from Revue Medicale de la Suisse 
Romande, Jan. 20, 1889. 



182 DIPHTHERIA; ITS NATURE AND TREATMENT. 

Seifert 1 and others. Dr. Seifert used it in a five per cent, 
solution in equal parts of alcohol and water applied by brush- 
ing- from twice daily to every three hours, and as a gargle in 
the following solution: chinoline 1.0 (15 grains); water, 500 
(1 pint); alcohol 50. (1^ ounces); oil of peppermint, two drops. 
Prof. Ahlfeld, 2 however, in one hundred and ten cases of chil- 
dren treated by this method, reported a mortalit} 7 of 28 per 
cent., and Dr. Lunin under similar treatment lost fifteen of 
twenty-eight patients. 

Resorcine. 

Resorcine is also a powerful antiseptic, and is less caustic 
than carbolic acid. It has been employed by Liblond 3 in solu- 
tion in glycerine (one in ten to fifteen parts) applied locally 
every two hours with favorable results, and like results from 
a similar use of it have been reported by Fraigniaud, 4 and H. 
Callias. 5 The latter employed a five to ten per cent, solution 
in water with a little glycerine by pencilling hourly, and a 
two per cent, solution every two hours by spraying. On the 
other hand Dr. Lunin lost nineteen of twenty-nine patients 
treated with resorcine. 

Sulphur. 

Sulphur has long been much employed in the treatment of 
diphtheria, mainly by insufflation, and its effects have been 
lauded by many. When thus used a portion of it is changed 
into sulphurous acid or sulphuretted hydrogen, both of which 
are powerful bactericides. Insufflation is a difficult procedure 
in the cases of young children, and the remedy itself is un- 
pleasant. Dr. H. Y. Knaggs, of London, 6 recommends the fol- 
lowing preparation as palatable and readily taken by children : 

1 Jahrb. f. Kinderh., 1884, p. 462. 

2 Jahrb. f. Kinderh., 1884, p. 463. 

3 Journ. de MeU de Paris, Dec. 20, 1884. 

4 Union M6dicale, 1885, p. 493. 

5 Quoted by Le Gendre, Archiv. de Laryngol., No. 1, 1887. 

6 Therapeutic Gazette, March 15, 1888, p. 153. 



TREATMENT. 183 

I£ Precipitated sulphur (pure),, . . 3 jss. 
Chocolate powder, . . . . 3 j. 
Cinnamon-water (concentrated, 1 in 40), fl. 3 j. 
Glycerine, fl. 3 iij. 

Mix the powders in a mortar ; then gradually add the glyc- 
erine with constant trituration, and lastly the cinnamon- 
water. Dose, half a teaspoonful to a teaspoonful every hour 
or oftener. Dr. Knaggs reports the treatment of seventy-five 
cases of diphtheria by this drug alone, with no fatal result. 

Rapid disappearance of membrane and corresponding gen- 
eral improvement are said to have followed the use of sulphur- 
ous acid in teaspoonful doses every half-hour to every two 
hours according to the gravity of the case. 1 

Hyposulphite of soda has been used during the past year 
by Dr. J. H. Fruitnight, 2 of this city, in connection with iron 
and other appropriate treatment in thirty cases with success- 
ful result in all but two. The remedy has been used in the 
strength of 3 j — 3 jss — 3 ij (according to the age of the patient) 
in two fluid-ounces of water, and of this a teaspoonful has 
been given every two hours. In a few of the cases the solu- 
tion has been applied with a brush or with the atomizer, the 
gentlest possible mode of application being always preferred. 

Chlorine, Bromine, and Iodine. 

Free chlorine, bromine, and iodine are among the most 
powerful bactericides. Chlorine kills bacteria in a watery 
solution of the strength of -g^yj-g-g-; bromine in that of ^Vo? an d 
iodine in that of T-gVo- I n internal use their germicidal effect 
is greatly diminished by their conversion in vital fluids which 
contain alkalies (as, for example, blood-serum) into chlorides, 
bromides and iodides. Their principal utility as antiseptics 
in the treatment of diphtheria is therefore in their local effect. 

For cleansing- and deodorizing a foul diphtheritic throat, 

^r. H. L. Snow, British Medical Journal, Oct. 8, 1887, p. 773. 
2 Archives of Paediatrics, October, 1888, p. 601. 



184 diphtheria; its- nature and treatment. 

solutions of chlorine have long- been much prized, and are 
among- the most efficient agents in our possession. The best 
of these is the liquor sodse chloratae, from two to four fluid - 
drachms of which in eight fluid-ounces of water may be applied 
every hour or two by gargling, irrigation or atomization. 

There has been much testimony to the successful employ- 
ment of bromine in the treatment of diphtheria; but this ex- 
perience of its utility has been by no means universal. Like 
many other powerful antiseptics it may doubtless be in skillful 
hands an effective therapeutical weapon against diphtheria; 
but its use in full strength or slight dilution is opposed by the 
considerations which have been referred to in regard to cor- 
rosive and irritating applications generally, and in high dilu- 
tions it has not been shown to have greater curative efficacy 
than other less disagreeable remedies. It is recommended by 
Dr. Hiller 1 in the following combination : 
1^ Potassii bromidi, 

Bromi, aa gr. iv. 

Aquas dest., . § vj. 3 ij. 

M. 

To be applied by brush to the pharynx every two or three 
hours and also used by inhalation. 

Dr. P. Hesse, 2 from his experience with one hundred and 
fifty cases, regards bromine as the most valuable local appli- 
cation in diphtheria. He used a solution of five decigrammes 
(gr. -§-) each of bromine and bromide of potassium in two hun- 
dred grammes ( f vj. 3 ij.) of water applied locally every two 
or three hours and also dropped on the sponge of an inhaler 
and so used for five minutes every half-hour. Latterly he 
used the solution by inhalation only, varying its strength 
according to the severity of the case. 

Dr. W. H. Thomson has employed bromine successfully in 
the treatment of a large number of cases of diphtheria, by a 

Deutsche Med. Wochenschr. , 1882, ix., 22, p. 328. 
2 Deutsches Archiv. f. Klin. Med., 1885-6, xxxviii., p. 479. 



TREATMENT. 185 

method of which the following- account is abbreviated from a 
fuller statement by himself which is contained in "A Treatise 
on Diphtheria " by Dr. A. Jacobi : Lawrence Smith's solutio 
bromini is first prepared by the following- method : " Take two 
ounces of a saturated solution of bromid. potass, in water; add 
to this, in a bottle, with constant shaking-, one ounce of bro- 
mine. It is better to add a part and then let it stand awhile 
before adding- the rest. Then fill up gradually, and with con- 
stant shaking-, with water, until it measures four ounces." It 
should not be ordered in a mixture with either glycerine or 
sugar, as it is thereby decomposed. If not exposed to too 
strong- a light it keeps for several days. 

. Locally this solution, mixed with an equal part of glycerine, 
or, in some cases, in full strength, is applied to the membrane 
with a hair-pencil as gently as possible. If the membrane is 
very extensive and the parts much swollen or difficult to reach, 
one half a drachm to one drachm of the solution to the pint of 
warm water is applied by douching with a Davidson's syringe. 
Internally from six to twelve drops of Smith's solution in a 
tablespoonful of sweetened water is given every hour, two, or 
three hours, according to the urgency of the case, and contin- 
uously, no other medicine being taken until the disappearance 
of the membrane. It should be swallowed promptly, as the 
disagreeableness of bromine is due much more to its fumes 
than its taste. 

Tincture of iodine has long been much employed as a local 
application in diphtheria, and many reports attest its efficacy 
as a caustic and antiseptic in causing the shrivelling and rapid 
disappearance of membrane. It has also been much used in 
such combinations as the following : 1 
^ Tinct. iodi., 

Tinct. ferri chloridi, . . . aa fl. 3 j. 

Acidi carbolici, . . . . . gr. x. 

Glycerini, . . . . . . fl. § ss. 

M. Apply by brush several times daily. 
'Dr. Keating, Boston Med. and Surg. Journ., 1885, Jan. 22. 



186 diphtheria; its nature and treatment. 

It has also been used internally; as by Dr. E. Adamson 1 
who treated fifty-five cases, including" some very bad ones, 
with doses of two or three minims in syrup aurantii and water 
every two hours to a child of six years with only two fatal 
results. The same remarks as to its great utility and its infe- 
rior eligibility to some other drugs in the treatment of diph- 
theria, both in stronger and weaker solutions, apply to iodine 
as to bromine, though in a somewhat less degree. 

Iodoform. 

" It is now regarded as an established fact that iodoform is 
not a parasiticide. ... It is believed by some to have a de- 
structive effect on the ptomaines generated by the bacteria 
through the action of the free iodine or iodine compound which 
is liberated/' 2 It cannot be doubted that iodoform has a val- 
uable antiseptic action, and its local anaesthetic effect and ten- 
dency to diminish secretion render it valuable in the treat- 
ment of diphtheria. It is important, however, that its use 
should be preceded or accompanied by other disinfectant 
measures. 

It may be applied in powder, by brush or insufflator, pure 
or mixed with half its weight of starch or with three parts of 
sugar. Good results in preventing the extension of membrane 
down the trachea after tracheotomy, by the insufflation of 
iodoform through the tube, have been reported by George 
Shirres 3 (who thus used ten to fifteen grains every four hours 
in two cases') and others. 

The following solution to be applied by pencilling is recom- 
mended by Le Gendre : 4 

Iodoform . . 2.50 grammes (38 grains). 
Balsam of tolu . 5 (75 minims). 

Ether . . .25. " (6 i drachms). 

1 Practitioner, London, July, 1885, p. 16. 

2 American Journal of the Medical Sciences, October, 1888, p. 401. 

3 London Lancet, July 24, 1886, p. 164. 
4 Archiv. de Laryngol., No. 1, 1887. 



TREATMENT. 187 

Dr. G. Mundie A prefers the application of iodoform to the 
throat in ethereal solution by spraying - . The ether appears 
to constringe the congested capillaries, and the iodoform is 
deposited in a thick film on the surface. 

Iodoform has been regarded by many as an especially val- 
uable agent in the treatment of the diphtheria of wounds. Its 
successful use in diphtheritic invasion of the tracheotomy 
wound has been reported by Plenio 2 and others in the form of 
powder, iodoform-vaseline or iodoform-collodion. It may be 
mixed with either of these excipients in the proportion of one 
to eight. 

Iodol has a similar action and like applicabilities to those 
of iodoform. 

Chloral. 

Hydrate of Chloral, first recommended in the local treat- 
ment of diphtheria by Dr. Accetella, 3 of Italy, has since been 
much employed and highly prized by many. It is an efficient 
antiseptic, hindering the development of bacteria in the 
strength of roVo- It is also a powerful irritant to raw or 
especially sensitive surfaces. Applied to the affected part by 
brush every hour or two in the form of the officinal syrup of 
chloral of the British Pharmacopoeia (ten grains to the 
drachm), it promptly arrests foetor and is said to cause the 
rapid solution and disappearance of membrane. 

Dr. A. Mercier 4 gives internally the syrup of chloral of the 
French codex (one in twenty) in doses of two, three or five 
grammes every half-hour or hour, no drink being allowed for 
some time afterward. In forty-eight hours after the treat- 
ment is begun the false membrane has dissolved and disap- 
peared, when the further use of the chloral becomes painful. 

1 London Lancet, June 5, 1886, p. 1103. 

2 Jahrb. f. Kinderh., Bd. xxii., H. 4. 

3 Campania Medica, No. 12, 1873. 

4 Le Concours MeU, Aug. 27, 1887, p. 411. 



188 diphtheria; its nature and treatment. 

By this treatment, Dr. Mercier has saved ninety-five out of 
one hundred cases. 

Oxygen. 

Oxygen is one of the most powerful of disinfectants and 
antiseptics. It has been principally employed in the treat- 
ment of diphtheria, locally by means of the permanganate of 
potassium, locally and internally in peroxide of hydrogen, and 
as conveyed through the blood to the tissues by means of the 
salts of iron. 

From the readiness with which it parts with oxygen, per- 
manganate of potassium is a powerful antiseptic, and in a 
solution of the strength of from three to five grains to the 
ounce of water is a most valuable local application in the 
treatment of diphtheria. Dr. Mason 1 prepares a stock solu- 
tion of two drachms of the permanganate in three ounces of 
distilled water, and uses a teaspoonful of this solution in one 
ounce and a half or two ounces of water as spray. It promptly 
arrests fcetor, which does not return. 

Peroxide of hydrogen, though not a new substance, has of 
late been brought prominently forward as an especially valu- 
able antiseptic in the treatment of diphtheria, and in the 
hands of some has, like most new remedies, produced brilliant 
therapeutical results. Such results have been claimed by 
Vogelsang 2 and by Hof mokl. 3 

Dr. M. P. Hatfield, 4 of Chicago, has used it successfully in 
eighteen cases, applied by swab every two hours, or a spray 
of the liquid diluted with seven times its bulk of water. He 
states that it neither acts as a solvent to, nor prevents the 
formation of, false membrane, but neutralizes its poison. 

The form in which this agent has been most generally used 
in this city is the Marchand solution, which contains fifteen 

1 Brooklyn Medical Journal, May, 1888. 
2 Archiv. f. Kinderh., B. viii., H. 2, p. 113. 

3 Wiener Med. Presse, 1886, xxvii., 18, 19. 

4 Archives of Paediatrics, Feb., 1888, p. 102. 



TREATMENT. 189 

volumes of the gas. Dr. H. Gifford, 1 having- in a series of ex- 
periments demonstrated that this preparation promptly kills 
bacteria and their spores, adds, " The instructions accompany- 
ing the Marchand solution advise diluting with about four 
times its bulk of water for use on ' mucous membranes as in- 
jections, etc/ A dilution of this strength was found not to 
have killed the pus cocci after an exposure for thirty minutes, 
a result which practically bars it as a germicide, though for 

its cleansing action it may still be valuable The fifteen 

volume solution is sharply irritating to the conjunctiva and 
nasal mucous membrane, and even the weakest solution men- 
tioned in the announcement, instead of being 'bland as water,' 
causes considerable smarting of the eyes and nose for a few 
minutes." 

I have tried the Marchand* solution in several cases of 
diphtheria, including one adult one, and my experience with it 
accords with that of Dr. Gilford as to its somewhat irritating 
and unpleasant effect when used with only slight dilution. In 
each case it was a relief to the patient and therapeutically 
advantageous when its use was discontinued and my usual 
spray of carbolic acid and lime-water was resumed. 

In a case related to me by another physician in which the 
peroxide was employed early and frequently both as spray 
and internally, the duration of the disease was not shortened 
thereb}^ and the patient died just at the time of apparent re- 
covery from the usual effects of toxic absorption, which the 
remedy had failed to counteract. 

In so far as I have been able to judge of its effects the 
peroxide of hydrogen, though it is a valuable antiseptic, has 
no greater curative efficiency in the treatment of diphtheria 
than the solutions of chlorine or of permanganate of potas- 
sium, with which remedies it may be classed ; but is to be pre- 
ferred to them on account of its less disagreeable taste. 

The application of ozone by the inhalation of ozonized air 
1 New York Medical Record, Sept. 1, 1888, p. 243. 



190 diphtheria; its nature and treatment. 

has been from time to time recommended in the treatment of 
diphtheria — the ozone being* produced by a chemical process in 
an inhaler. Dr. Seneca D. Powell a few years since exhibited 
to the Post-graduate Clinical Society of this city an inhaler in 
which ozone is g-enerated by the action of electricity, and which 
he had used with good effect in various diseases, among- which 
was diphtheria in several cases — its effect having- been the 
rapid disappearance of false membrane and the correspond- 
ingly rapid reduction of temperature. I am informed by the 
deviser of this instrument, Mr. Harvey Lufkin of the C. & C. 
Electric Motor Company, that it will soon be manufactured 
and offered for sale. 

Benzoate of Sodium. 

Benzoate of Sodium has only a mild antiseptic action, since 
in a solution of ¥ o~o it merely hinders the growth of anthrax 
bacilli (Koch). Letzerich, having- been led by the experiments 
of Graham Brown to the conclusion that it is fatal to the 
microbe of diphtheria, and consequently a specific for that dis- 
ease, employed it therapeutically with nearly uniform success 
by the following- formula : 

I£ Sodii benzoat, . . . . 3 j. gr. xv. 

Syr. aurantii, . . . . 3 ijss. 

Aquge menthse pip., 

Aquae dest., . . . aa ?j.,3 ij. 

M. 
To be given in divided hourly doses in the twenty-four 
hours. He subsequent^ increased the daily dosag-e to from 
If to 3f drachms to children under fifteen years, and from 3f 
to 5^ drachms for older patients. 

From this and similar uses of it favorable results have 
been reported by Kien, Ferreol and many others, the most 
notable being- those related by Brondel, 1 who claimed to have 
treated two hundred cases with uniform success by the fol- 

1 Bulletin Gen. de Th6rap., Nov. 15, 1886, p. 416. 



TREATMENT. 191 

lowing* method : He gave hourly a tablespoonful of a solution 
of the benzoate (fifteen grains to the fluid ounce), together 
with one sixth of a grain of the sulphide of calcium in syrup 
or granule, and sprayed the throat every half -hour with a ten 
per cent, solution of the benzoate. He also employed vapori- 
zation of water containing carbolic acid, turpentine and oil of 
eucalyptus. 

Favorable results from the use of the benzoate of sodium 
have not, however, been obtained by all who have employed it. 
Thus Guandige, of Vienna, 1 among seventeen children treated 
by the method of Letzerich, had eight deaths. While there is 
reason to believe that this agent has positive therapeutical 
value, the hope that it would prove to be the desired specific 
has not been realized. 

Chlorate of Potassium. 

Chlorate of Potassium has long held a leading place 
among valuable remedies in the treatment of diphtheria. It 
is a mild antiseptic, and its effect in favorably modify- 
ing catarrhal inflammation in the mucous membrane of the 
mouth and throat is well established. It is to this effect upon 
the inflammation that its utility in the treatment of diph- 
theria is doubtless mainly due. 

The important fact that chlorate of potassium is in exces- 
sive doses a most dangerous poison has been illustrated in 
quite numerous instances. Dr. V. Afanasieff 2 has collected 
from international literature fifty-one such cases, forty-six of 
which were fatal. He has also found by experiments on ani- 
mals that in acute cases of poisoning by the chlorate of potash 
there is rapid and profound disorganization of the blood, its 
detritus accumulating in the liver, spleen, lymphatic glands, 
bone-marrow and kidneys, the urinary tubules becoming 

1 Quoted by Le Gendre, loc. cit. 

2 "St. Petersburg Inaugural Dissertation," 1885, Abstracted in Pro- 
vincial Medical Journal, March, 1888, p. 134. 



192 DIPHTHERIA; ITS NATURE AND TREATMENT. 

blocked up and impassable, the renal functions ceasing- and 
acute parenchymatous nephritis with uraemic poisoning- re- 
sulting. In chronic cases, parenchymatous nephritis is soon 
followed by intense interstitial nephritis with its usual conse- 
quences; and in all cases the blood assumes a characteristic 
chocolate color. 

The cases of poisoning referred to have been the result of 
taking at one dose known quantities of the salt varying from 
three to ten drachms, or the reckless swallowing of large 
quantities of a saturated solution or super-saturated mixture. 

These facts show that this drug, like most other valuable 
therapeutical agents, is a poison when used in certain quanti- 
ties, and make it incumbent on physicians not only to exercise 
due moderation in the doses of it which they prescribe to their 
patients, but also to correct the prevailing popular belief that 
it can safely be taken in unlimited quantities ; but they do not 
teach that when used in suitable doses and in proper dilution 
it is liable to have an injurious cumulative effect, which is 
indeed contradicted by a vast array of experience. 

Dr. H. Seeligmuller x refers to the experience of Dr. von 
Mering as corroborating his own, that the chlorate of potas- 
sium is a most valuable remedy, and is only dangerous when 
given on an empty stomach, so as to be rapidly absorbed into 
the circulation in large quantity. Dr. Seeligmuller's doses 
(from half a tablespoonful to a tablespoonful of a five percent, 
solution hourly) are large enough to require this caution in 
their use. 

Dr. Hullmann, 2 of Halle, who uses a four per cent, solution 
in hourly doses of from a teaspoonful to a tablespoonful, has 
always had good results and never anj T bad effects therefrom. 
In twenty years he has used this remedy for 3511 patients, in- 
cluding 571 cases of diphtheria. Among the latter he has had 
only six deaths. In diphtheria he has used also lime-water 

1 Deutsche Med. Wochenschr., 45, 1883. 
2 Deutsche Med. Wochenschr., 52, 1883. 



TKEATMENT. 193 

and weak solutions of permanganate of potassium locally. 
He regards chlorate of potassium as the best of all remedies 
which have been proposed for the treatment of diphtheria. 
Similar statements have been made by many. 

During- the past twenty years I have prescribed the chlo- 
rate of potassium in thousands of cases of sore throat and 
scarlatina, and in many hundreds of cases of diphtheria, usu- 
ally in a four per cent, solution. Many of these patients have 
taken it in teaspoonful doses hourly or half -hourly for several 
weeks continuously. In no instance have I observed or had 
any reason to think that its effect has been injurious. So far 
from its having- occasioned kidney affections in my cases of 
scarlatina and diphtheria, the infrequency of nephritis and 
albuminuria has been remarkable even in many very grave 
cases of the latter disease. 

I have never regarded it as a specific, but rather as a valu- 
able adjuvant in the treatment of diphtheria, and have usually 
employed it in connection with other remedies. (See page 219 ). 

Borax. 
Borax is a very valuable antiseptic. It is especially 
adapted to local use in the treatment of diphtheria by its 
bland and unirritating character, its cleansing effect, and its 
harmlessness in ordinary doses. It has therefore been much 
employed in the form of the glycerine of borax applied by 
brush; in powder, by insufflation; and in a watery solution of 
the strength of from one to five per cent, by gargling or irri- 
gation. 

The following combination is recommended by Le Gendre : x 
^. Boracis, 

Potassii chloratis, aa gr. 75. 

Acidi carbolici, gr. 4. 

Glycerini, . . . . . 3 2-J. 

Mellis, . 3 7|. 

M. To be applied with pencil. 

1 Archiv. de Laryngol., No. 1, 1887. 
18 



194 diphtheria; its nature and treatment. 

Dr. Noel 1 has lately announced that he has given borax 
internally with good results in the following* doses : 

To children under one year . 8 to 15 grains daily 

from two to five years 15 to 23 
" five to ten years 30 

" adults 45, 60 or 75 « 

These quantities are given in solution in divided doses 
hourly. 

The drug produces abundant salivation. Dr. Noel thinks 
that, being eliminated by the salivary glands and the mucipar- 
ous glands of the throat, it tends to soften and remove the 
false membrane. This was the only medicine given during an 
epidemic to sixty patients, of whom only two or three died. 

Boracic acid has been preferred and employed by some. It 
may be locally applied in saturated solution and used as a 
gargle or in spray in a solution of the strength of from one 
to three per cent. 

Oil of Turpentine. 

Oil of Turpentine is a powerful antiseptic. In a solution of 
the strength of tj.Votf ft hinders the growth of bacteria. The 
vapor of oil of turpentine mixed with air arrests the secretion 
of mucus. The drug when taken internally is partly excreted 
by the lungs and acts on the mucous membrane, lessening its 
secretion; but a watery solution of it applied to inflamed 
mucous membranes increases secretion and diminishes vascu- 
lar congestion. Large doses are liable to act as a purgative, 
and moderate ones are apt to cause dysuria and hsematuria. 

Oil of turpentine has been used by some as a local applica- 
tion. Schmiedler 2 prefers it to any other. He applies it pure 
in cases in which the seat of the affection is accessible every 
three hours, and finds that it is unirritating, rapidly dissolves 
false membrane, and has a very decided antiseptic action. 

1 Le Concours MM., May 26, 1888. 

2 Rev. Mens, des Mai. de FEnf., June, 1888. 



TEEATMENT. 195 

There is much recent testimony to the benefit derived from 
the internal use of oil of turpentine in the treatment of diph- 
theria, especially in the laryngeal form of the disease. 

Bosse 1 gave eight grammes (two drachms) to children of 
from two to seven years of age, and twelve grammes (three 
drachms) to older patients, pure, followed by milk, once daily 
in forty-three cases, including very severe ones, with distinct 
effect in modifying and shortening the disease, and with only 
two fatal results. 

Dr. Satlow 2 followed Bosse's method in forty-three severe 
cases, adding one gramme (Tf[xv.) of ether to fifteen grammes 
(f. 3 iij., gr. xlv.) of turpentine to diminish its nauseating effect. 
In three cases the imminent necessity of tracheotomy was 
obviated by the treatment, and only three per cent, of his 
patients died. 

Dr. Roese 3 treated fifty -eight cases by the following 
method: Teaspoonful doses of oil of turpentine (with four 
minims of ether in each dose) were given three times a day. 
A tablespoonful of a two per cent, solution of salicylate of 
sodium was given every two hours; a warm one per cent, 
solution of potassium chlorate was used as a gargle, and an 
ice-bag was applied externally. His results were, rapid sub- 
sidence of fever and subjective symptoms, no exacerbation of 
the local affection after the commencement of treatment, 
obviation of the danger of asphyxia, except in one case in 
which tracheotomy was performed, and decided shortening of 
the duration of the disease. The turpentine was discontinued 
as soon as the fever had subsided and the local symptoms had 
improved. In most cases not more than from three to five 
drachms were required, though in several instances as much as 
fifteen drachms was employed. Only three of his patients died. 

Dr. A. Sigel, 4 in the Olga Hospital in Stuttgart, treated 

1 Berlin. Klin. Wochenschrift, No. 43, 1880, and No. 10, 1881. 

2 Deutsche Med. Zeitschrift, 1883, p. 157. 

3 Therapeutische Monatschefte, October, 1887. 
A \rch. f. Kinderh., vi., 2. 



196 



diphtheria; its nature and treatment. 



forty-seven cases, including- some very grave ones, with tur- 
pentine in teaspoonful doses once or twice daily, with seven 
deaths, or 14.9 per cent. In four of these cases the necessity 
of tracheotomy was imminent, hut was averted hy the treat- 
ment. Of sixteen other patients treated with salicylic acid, 
chlorate of potash, etc., seven died, or 43 per cent., and of 
twenty-four treated with sublimate six died, or 25 per cent. 

Dr. S. Baruch, 1 from his favorable experience in the use of 
this remedy in 39 cases, says : " In only one case have I observed 
temporary hematuria ; in none strangury .... I administer 
ol. terebinth, in doses of one drachm to half an ounce to chil- 
dren from six to fourteen years of age, once a day, oftener in 
cases demanding it. It may be given pure, followed by milk or 
mixed with milk or in emulsion. Vomiting occurs sometimes 
after the first dose, but it is usually retained afterwards. In 
about fifty per cent, of the cases it produces a laxative effect. 
It always stimulates the secretions of kidneys and skin; the 
odor is quickly detected in these as well as in the faeces." 

In the Oldenburg Hospital for Children in St. Petersburg, 
264 of 296 very grave cases of diphtheria were treated in 1882, 
according to the report of Dr. Lunin, 2 in different groups by 
the following remedies and with the following results in 
" fibrinous " and " septic " cases respectively : 





Fibrinous Form. 


Septic Form. 


Totals. 


Treatment. 






Percent- 






Percent- 






Kate 




Cases. 


Deaths. 


age of 
Deaths. 


Cases. 


Deaths. 


age of 
Deaths. 


Cases. 


Deaths. 


Per 

Cent. 


Bichloride . . 


43 


13 


30.2 


14 


13 


92.9 


57 


26 


45 


Chloride of iron 


43 


14 


32.6 


51 


39 


76.5 


94 


53 


56 


Chinoline . . 


19 


6 


31.6 


9 


9 


100 


28 


15 


53 


Resorcin . . . 


10 


2 


20 


19 


17 


89 


29 


19 


65 


Bromine . . . 


15 


7 


46.7 


18 


16 


88.9 


33 


23 


69 


Turpentine . . 


12 


1 


8.3 


11 


9 


81.8 


23 


10 


43 
















264 


146 


55.3 



1 " Therapeutical Memoranda on Diphtheria, with Special Reference 
to the Value of Large Doses of Oil of Turpentine," New York Medical 
Record, Dec. 24, 1887, p. 784. 

2 St. Petersburg Med. Wochenschr., 6 and 7, 1885. 



TREATMENT. 197 

The bichloride was applied locally by brushing- with a y^o 
solution every two hours and irrigation with a -g-gVo solution 
hourly. 

The chloride of iron was given in doses varying" from one 
drop every two hours to two drops every half -hour, with irri- 
gation every hour by a three per cent, solution of boric acid. 

Quinoline was applied every two hours in five per cent, 
solution in water and alcohol, and used by irrigation or spray 
in -g^o solution. 

Resorcin was applied in ten per cent, solution every two 
hours, and used in one per cent, solution as gargle or spray. 

Bromine was used in -^o solution, applied every one to 
three hours, and in a solution two thirds of that strength in- 
haled every half -hour to every hour. 

Turpentine was given in doses not exceeding ten drops 
hourly for periods of from two to ten days, with a gargle of a 
three per cent, solution of boric acid. 

In thirty-two additional cases treated by other methods 
there were eighteen deaths, or 56 per cent. The mortality in 
the entire series of 296 cases was therefore 164, or 55.4 pei 
cent. 

These figures show the best results from turpentine in the 
fibrinous form, and the worst from bromine; the best from 
chloride of iron in the septic form, the worst possible from 
chinoline, and nearly as bad from bichloride of mercury. 

Antiseptic Aerotherapy. 

Oil of turpentine has been much employed by vaporization. 
It may be poured from time to time into a vessel in which 
water is kept constantly at boiling point, and the vapor may 
be allowed to diffuse itself through the air of the room or con- 
ducted through a tube near to the patient's mouth. Dr. Del- 
thil x recommends that in cases of no especial gravity it be 
evaporated by placing it in a suitable vessel which is set into 
Journal de Med. de Paris, July 12, 1886. 



198 DIPHTHERIA; ITS NATURE AND TREATMENT. 

another one containing water which is kept at a temperature 
of 60° C. (140° F.). The turpentine should be crude, not recti- 
fied. In a large room several such receptacles should be used. 

He recommends the employment of antiseptic fumigations 
in grave cases by the following method : A mixture of two 
pounds of coal tar, four ounces of oil of turpentine, two 
drachms of resin of benzoin and three and one quarter ounces 
of cajeput oil, or a mixture of seven ounces of coal tar and two 
ounces and six drachms of turpentine, or turpentine alone 
may be used. About two ounces of either is poured into a 
large metallic dish, and then lighted and allowed to burn 
steadily, renewal being required about once in two hours. A 
small room should be used for the purpose, into which the 
patient may be carried and allowed to remain for half an hour 
at a time, after which he may be returned to the regular bed- 
chamber, in which the evaporation of turpentine b}^ the method 
previously described is maintained. Dr. Delthil has found 
that the fumes are well tolerated by patients, and reports 
favorable results from this method of treatment in one hun- 
dred and twenty-six out of one hundred and thirty-four cases. 

Renou 1 reports the successful employment of the following 
method of antiseptic aerotherapy: On one or two small 
kerosene stoves water is kept constantly at the boiling-point. 
Into this is put every two hours one or two drachms of the 
following mixture: Alcohol, 468 grammes; carbolic acid, 280 
grammes; benzoic acid, 112 grammes; and salicylic acid, 156 
grammes. The apparatus must be so placed that the vapor 
can be readily inhaled by the patient. 

Eucalyptus. 

Dr. J. Murray-Gibbes 2 extols the virtues of eucalyptus used 
in the following manner : The patient is kept in an improvised 

1 Bulletin de Soc. de MeU d' Angers, 1885, xiii., p. 112. 

2 London Lancet, 1883, i., p. 316, and Australian Medical Journal, 
October 15, 1888. 



TREATMENT. 199 

tent, and the air is charged with vapor impregnated with the 
oil of eucalyptus, by placing the dried leaves in a vessel of 
boiling water beside the bed. This should be renewed every 
half-hour. The patient is kept in this atmosphere until the 
disease has disappeared. Dr. Murray Gibbes has, since 1881, 
treated 163 patients in this way, with only one death, though 
other physicians have lost many patients. A colleague has 
treated 305 cases in the same manner with only one death. 

Thymol, which is a powerful antiseptic, has been utilized in 
the treatment of diphtheria. It may be used by the following 
formula, as gargle or spray: 1 Thymol, 3j.; Glycerine, 3 ii j . ; 
Water, % jss. Oil of peppermint, which is also strongly anti- 
septic, has been found efficient used " freely and copiously" as a 
local application twice daily in the early stage of diphtheria. 2 
The insertion into the nostrils of plugs of cotton saturated 
with a twenty per cent, oily solution of menthol in cases in 
which the nares were entirely occluded with membrane is said 
to have caused its rapid disappearance and the arrest of the 
diphtheritic process. 3 Engelmann 4 has found that vinegar is 
a most efficient antiseptic. Used pure for local application, 
diluted with two or three parts of water as spray, and with 
four parts of water as a gargle, it has given better results 
than any other agent. It is energetic without being irrita- 
ting. It also possesses in a high degree the power of pene- 
trating animal tissues. Citric acid in the form of lemon-juice 
has also been highly recommended by Fieuzal 5 and others. 

Dr. Jules Simon, of Paris, 6 employs the following local treat- 
ment : Local application every hour by day, and every two 
hours at night of lemon-juice or vinegar or pure red wine, and 
gargling or irrigation every two hours with a hike- warm solu- 

1 Dr. Da Costa, K Y. Med. Record, Feb. 27, 1880. 

2 Dr. L. Braddon, London Lancet, March 24, 1888. 
3 Cholewa, in Therap. Monatsch., 1888, 11, p. 284. 
4 Centr. f. Klin. Med., 1886, No. 14. 

5 Bull, de la clin. nat. ophth., vol. vi., p. 57. 

6 Rev. Mens, des Mai. de l'Enf., August, 1885. 



200 diphtheria; its nature and treatment. 

tion of boracic acid (1 : 25) or borax (1 : 50) or potass, chlorat. 
(1 : 25) or lime-water or vinegar-water. 

Hydronaphthal with Papain. 

Dr. W. C. Caldwell, 1 in order to accomplish at the same 
time the solution of false membrane and local disinfection in 
the treatment of diphtheria, has combined a peptonizing- fer- 
ment and an antiseptic in one mixture. Having referred to 
the general tendency of the latter class of substances to pre- 
vent the action of the former, he states that, nevertheless, in 
one case of diphtheria in which he used bichloride of mercury 
with papain, "the pseudo-membrane was readily dissolved, 
and the temperature fell from 103° to 99° from nine A. M. to 
six p. m. . . . Hydronaphthal is a powerful antiseptic which 
acts in a neutral or acid menstruum, and, besides, is not poi- 
sonous. When it is used with papain to spray the throat in 
diphtheria, the membrane rapidly dissolves." 

Dr. Caldwell has employed the following mixture in the 
treatment of seven cases of diphtheria : 

I* Papain, 3 ij. 

Hydronaphthal, gr. iij. 

Acidi hydrochlorici dil., . . . gtt. xv. 

Aq. destil., . . . . . . ad f-iv. 

M. 

This was applied by " spraying the throat every half -hour 
until temperature is reduced and breathing is easy; then 
every hour, unless asJeep. In these cases, when the spray 
was used thoroughly, the temperature fell in from four to 
eight hours." To be effective, the spray must be thoroughly 
and directly applied to the affected surfaces. In the seven 
cases referred to, the result of the treatment was favorable 
in all but one — a laryngeal case in which cyanosis was present 
when treatment was begun. 

1 Archives of Pediatrics, February, 1889, p. 97. 



treatment. 201 

The Chloride of Iron. 

So great a mass of clinical evidence as to the value of the 
chloride of iron in the treatment of diphtheria has been pre- 
sented to the profession, and that value is now so generally 
recognized, that it would be superfluous to adduce statistics to 
prove it. The occasional denials of its efficacy, based on expe- 
rience of its unsuccessful employment, which appear in medi- 
cal literature, may be regarded as merely illustrating' the 
indisputable fact that it is not a specific, and that its useful- 
ness is subject to limitations. 

The local astringent action of the drug- has already been 
referred to ; it is also a valuable local antiseptic. Internally 
it is undoubtedly the most efficient known antidote to the poi- 
sonous action of the putrefaction -products of diphtheria in 
the system at large. It evidently does not produce this effect 
by destroying- the microbes of the disease, but by reinforcing 
the vital processes by means of which the poisons produced by 
them are resisted, destroyed and eliminated. The tendency of 
these poisons, when absorbed into the circulation, is to the 
rapid production of anaemia and haemic disorganization, nerv- 
ous prostration, and the consequent arrest of all vital func- 
tions. " Ferric salts, after absorption into the blood, increase 
not only the number of the blood-corpuscles, but also the per- 
centage of haemoglobin contained in them, and may also cause 
a little free iron to be contained in the serum. By thus in- 
creasing- oxidation in the tissues they increase the functional 

activity of all the organs Iron also circulates with the 

bile, and it is probable that the beneficial effects of large doses 
may be due to the action of the iron upon the liver." (Brun- 
ton.) Iron is also a tonic to the vascular system, and ferric 
chloride has been supposed to have an especial stimulant 
action on the nervous sytem. 

The internal administration of the chloride of iron has lit- 
tle effect on the duration of the membranous affection. In the 



202 diphtheria; its nature and treatment. 

laryngeal form of the disease it is probably useless, except to 
oppose concomitant blood-poisoning*, and as a tonic. In the 
distinctively inflammatory stage and form of diphtheria its 
value is mainly limited to its local astringent and antiseptic 
action in the pharynx. Its special and unequalled utility is 
seen in its preventing or limiting the occurrence of constitu- 
tional poisoning and counteracting its effects in the septic 
form or stage of the disease. Its power to accomplish this 
object is, however, not unlimited. It is inadequate in cases in 
which the constitutional poisoning is especially rapid and in-, 
tense, and in many cases in which other essential antiseptic 
measures are neglected, as, for instance, the cleansing of the 
nares in nasal diphtheria. 

There are unfortunately other limitations to its utility. In 
quite a number of cases it is irritating to an especially sensi- 
tive throat, and it sometimes causes vomiting. These effects 
may depend on the injudicious manner of its administration, 
but in some cases its use in any form is inadmissible. 

The administration of large amounts of the drug is con- 
sidered by many a sine qua non to obtaining its beneficial 
local and constitutional effect. 

Dr. Aubrun, 1 in 1860, recommended its use in very frequent 
doses. His usual mode of administering it was to have from 
twentj- to forty drops of an aqueous solution of the perchlo- 
ride, consisting of one part of the anhydrous salt in three parts 
of water, put into a cup of water, and of this two teaspoonfuls 
were taken by the patient every five minutes while awake, 
and every fifteen minutes while sleeping. Robert Druitt, 2 in 
1861, practiced and recommended giving it in doses as large 
as two drachms every two hours. Both of these physicians 
reported favorable results from this heroic medication, and 
like results from similar practice have been reported by many 
subsequent writers. 

1 Gaz. Med. de Paris, Nov. 26, 1860, p. 765. 

2 British Medical Journal, Feb. 23, 1861, p. 208. 



TREATMENT. 203 

Dr. A. Jacobi 1 says, "To be of any efficacy muriate of iron 
must be given in large doses, frequently repeated. Five to 
fifteen drops every quarter, half, or every hour is a dose that 
alone fairly tests the effective powers of the medicine." 

Dr. J. E. Winters 2 makes the important discrimination 
that " where there is marked sepsis and tendency to capillary 
haemorrhages the dose should be larger than in a case of a 
less septic and more marked inflammatory character," and 
recommends that in the former type of the disease at least 
one drachm of the tincture should be administered every hour 
to a child two to five years old. 

In those cases in which a marked tendency to septic poi- 
soning is manifested the. use of the drug should, if necessary, 
be pushed toward the limit of tolerance, and from one to three 
ounces daily may succeed where less would fail. But such 
heroic dosage is, in actual practice, especially in the treatment 
of young children, attended with grave difficulties, and is for- 
tunately in the great majority of cases unnecessary. When 
other appropriate treatment is employed, from one and a half 
to three drachms of the tincture of iron given daily will usu- 
ally have the desired effect. 

It has also been considered necessa^ by some that the 
tincture of iron be administered in concentrated form. While 
this may doubtless enhance its beneficial local effect in some 
cases, it may have an irritating effect in others. But the 
great objection to administering it in this form to children is 
the fact that its unpleasant acrid and styptic taste, and the 
smarting which it often occasions is very liable to arouse their 
violent opposition to taking it and necessitate struggles, the 
undesirableness of which has already been alluded to. That 
this is no merely fanciful or unusual result I know from obser- 
vation in many cases. The evil referred to may be obviated 
in most cases by giving the tincture of iron in six or eight 
parts of glycerine. (See formula page 220 .) 

1 American Journal of Obstetrics, 1875, p. 660. 2 Loc. cit. 



204 diphtheria; its nature and treatment. 

Quinine. 

Quinine has been much employed in the treatment of diph- 
theria as an antiseptic, an antipyretic and a tonic. 

It hinders the growth of anthrax bacilli in a solution of the 
strength of -^ and prevents it in that of g-J-^. It may doubt- 
less exert a valuable local antiseptic action, but is inferior in 
this respect to other agents which are less disagreeable to the 
taste. 

High temperature is generally limited to the early and in- 
flammatory stage of the disease, and then other measures for 
reducing it are more efficient and appropriate than antipyretic 
doses of quinine. 

For tonic effect in the later stage of the disease, and in the 
period of convalescence, quinine, in doses of from half a grain 
to a grain or two, three or four times a day, or the compound 
tincture or wine of cinchona, or the elixir of calisaya, may be 
very useful. 

The unpleasant bitterness of quinine and its consequent 
tendency to excite nausea are important obstacles to its use 
in the treatment of diphtheria in young children. 

Alcohol. 

The antizymotic and antiseptic actions of alcohol are well 
known. It hinders the growth of anthrax bacilli in a dilution 
of 1 : 100, and prevents it in that of 1 : 12.5. Its main utility, 
however, in the treatment of diphtheria probably results from 
its assisting to maintain nutrition and opposing the tendency 
to adynamia and heart-failure by its action as a food and a 
stimulant. 

The principal indications for its use are the following : 
When milk or other food is refused by the patient or taken 
only in insufficient quantities, the addition of a little brandy 
or wine will sometimes cause it to be relished and taken more 
freely and will also promote its digestion. 



TREATMENT. 205 

In marked depression of the vital powers from the com- 
bined effects of fever, prolonged suffering-, fatigue, loss of 
sleep, and an insufficiency of nourishing food, even if the symp- 
toms of septic poisoning are absent, alcoholic stimulants, care- 
fully and moderately administered, may have a valuable sus- 
taining effect, as in other diseases. 

At the first appearance of symptoms which denote consti- 
tutional poisoning by the septic products of the disease, such 
as pallor with weakness, enfeebled heart-action, etc., alcoholic 
stimulants should be administered. The quantity and fre- 
quency of the doses must depend on the gravity of the symp- 
toms, the effect of the remedy in controlling them, and the 
tolerance of the stomach. The symptom to be especially 
regarded is the pulse. If that be feeble and unduly slow or 
rapid or irregular the amount of stimulant given must be 
increased, if possible, until its favorable effect is manifested. 
Intoxication in the ordinary sense of the term is not usually 
produced under these circumstances. The amount given must 
often be large, and may sometimes be heroic. I have in many 
instances given three or four ounces of brandy or whiskey daily 
in teaspoonful doses, well diluted, every hour or half hour to 
children under five years of age, without injurious effect, and 
in some cases with evident benefit. I have repeatedly seen it 
given in more than twice that quantity, but although favora- 
ble results are reported from this use of it where less has 
failed, I have never seen an instance of them. 

Brandy or whiskey may be given in the form of milk punch 
or made into a toddy or diluted with carbonated waters; or 
egg-nog or wine-whey, or Malaga, Burgundy or port wine 
may be more acceptable to the patient, and sometimes cham- 
pagne has a particularly good effect. 

The most important limitation to the giving of alcoholic 
stimulants in diphtheria results from the intolerance of them by 
the stomach. When in every form they are found to excite 
repugnance or nausea and to thus prevent the taking of other 



206 diphthekia; its nature and treatment. 

food, persistence in their use can only be injurious. The pos- 
sibility of causing- subacute gastritis by giving* too strong* 
and too frequent doses of alcoholics should not be forg-otten. 
" Sometimes when given very freely to support the failing* cir- 
culation, they have this effect, the result of which is that both 
food and stimulants are vomited, and the patient is brought 
to death's door." (Brunton.) In view of the close sympathy 
which is well known to exist between the condition of the 
stomach and the function of the heart througii the nervous 
system, it is evident that the irritation or overtaxing* of the 
former by too heroic stimulation may inhibit the latter, and 
thus produce the very condition of heart-failure which it was 
intended to prevent. 

The indications for the use of alcohol which have been 
stated by no means justify its indiscriminate use in the treat- 
ment of diphtheria. It is not called for in the early stag*es of 
most cases. It is in no sense a specific for diphtheria. It 
should be remembered that when it is used without indication 
or in excess of the quantity indicated, though it may in some 
cases be well tolerated, it is yet a poison. It is especially 
liable to be so to the delicate organizations of children. "Ab- 
sorbed into the blood it lessens oxidation, and will conse- 
quently diminish oxidation in the tissues." (Brunton.) " In cer- 
tain circumstances, such as febrile diseases, it may be a very 
useful food; but in health, when other foods are abundant, it is 
unnecessary, and as it interferes with oxidation it may be a 
very inconvenient kind of food." (Ibid.) " By increasing the 
circulation it may stimulate the functions of all the nerve- 
centres and render them for the time being capable of greater 
activity, .... but its action on the nerve-centres themselves is 

a paralyzing one Its action on the nerve-tissues seems 

to be one of progressive paralysis." (Ibid.) " In the Ashan- 
tee campaign the effect of alcohol as a stimulant compared 
with beef-tea was carefully tested. It was found that when a 
ration of rum was served out the soldier at first marched 






TREATMENT. 207 

more briskly, but after about three miles had been traversed 
the effect of it seemed to be worn off, and he then lagged more 
than before. If a second ration was then given its effect was 
less marked, and wore off sooner than that of the first. A 
ration of beef-tea, however, seemed to have as great a stimu- 
lating power as one of rum, and not to be followed by any 
secondary depression." (Ibid.) 

The wise therapeutist, in the treatment of diphtheria, as of 
other diseases, will reserve this most valuable agent to aid 
him in tiding his patient over those crises in which its use is 
definitely indicated, rather than attempt by its early, indis- 
criminate and excessive administration to prevent their occur- 
rence — an attempt which will too often tend to defeat its own 
object. 

In proportion as other and more appropriate measures for 
preventing the occurrence of serious septic poisoning and sus- 
taining the strength of the patient are early and efficiently 
carried out, the proportion of cases in which the use of alco- 
holic stimulants is called for is diminished. I was thus enabled 
to say in my second report (see page 212) : "The large major- 
ity of cases in the present series, as in those that I have previ- 
ously reported, have been treated absolutely without them." 
That the cases of which this could be stated were neither 
doubtful nor trivial ones was conclusively shown in the re- 
ports referred to. All my subsequent experience and obser- 
vation have tended to confirm my belief that in a large 
majority of all cases of diphtheria which are early and well 
treated the indications for the use of alcoholic stimulants 
which have been referred to do not present themselves, and 
that their use without those indications is not advantageous, 
but the reverse. 

Dr. J. Lewis Smith * relates the following typical experi- 
ence : "Although an advocate of the liberal use of alcohol, I 
cannot regard this agent as a specific. When I commenced 
1 Diseases of Children, p. 319. 



208 diphtheria; its nature and treatment. 

serving- in the New York Foundling- Asylum in May, 1878, the 
quarantine wards contained four children between the ages 
of three and five years who had been sick a few days with 
severe diphtheria, and it was evident at a glance that they 
must soon perish with the ordinary mild sustaining treatment. 
Quinine, iron, the most sustaining food and a moderate 
amount of alcoholic stimulants were being given, and we de- 
termined to increase the Bourbon whiskey to a teaspoonful 
every twenty to thirty minutes, day and night. Neverthe- 
less, whatever the result might have been with the earlier 
commencement of this treatment, the blood-poisoning was 
now too profound, and one after the other died." 

Those who, unlike Dr. Smith, regard the heroic use of 
alcohol as a specific for diphtheria, explain such failures by 
the lateness and insufficiency of its administration. I know 
of no ground for the assumption, either in our knowledge of 
its action or the statistics of treatment. I have seen quite a 
number of cases, some of them in my own earlier practice and 
others in consultation, in which as free use of alcohol as that 
just referred to was begun at the outset of grave and malig- 
nant cases, and failed as signally to arrest the fatal progress 
of the disease. Our main dependence for effecting that object 
must be on the early employment of other and more appro- 
priate measures, to which alcoholic stimulants may often be a 
most valuable, and sometimes an indispensable, adjuvant. 

Specifics. 
Copaiba and Cubebs. 
Copaiba and cubebs were formerly very extensively used, 
especially in France, in the treatment of diphtheria. Dr. 
Trideau 1 claimed to have employed them with rapidly success- 
ful effect in more than three hundred cases. The former 
remedy having been generally abandoned on account of its ir- 
ritant effect upon the digestive organs the latter continued to 
1 Traitement de l'angine couenneuse par les balsauiiques, Paris, 1874. . 






TREATMENT. 209 

be much used. It was given in the form of the oleoresin, 
either in capsules or in emulsion with syrup of acacia, in doses 
of from 1.50 grammes (22^ minims) to 3 grammes (45 minims) 
daily. M. Sanne, 1 having employed this treatment in a great 
number of cases, states that he has never observed from it 
any well demonstrated action which can compensate for the 
disgust which it inspires in patients and its tendency to excite 
purgation. 

Cardiac Depressants. 
Veratrum Viride. 

The employment of depressing remedies, except to fulfill 
some imperative and temporary indication, is generally con- 
demned and avoided in the modern treatment of diphtheria. 
From what has been stated elsewhere (page 71) as to the usual 
character of the disease in its early stages, it is evident that 
this exclusion should not be too indiscriminate and arbitra^. 
The following statements by Dr. J. M. Boyd, 2 of Knoxville, 
Tennessee, in so far, at least, as they relate to the early stage 
of certain types of the disease, are worthy of consideration : 

The characteristic pulse of diphtheria is described as 
"rapid/' "small/' "hard," "tense," "wiry." The speedy re- 
duction of this rapidity to the normal or sub-normal rate has 
in his experience been followed by the mitigation of the in- 
flammatory process and the melting* away of false membrane. 
He employs for this purpose the tincture of veratrum viride,. 
commencing with moderate doses, according to the age of the 
patient, and increasing them until the desired effect upon the 
pulse is produced. To an adult he gives three drops of Nor- 
wood's tincture every two hours, increasing by one drop at 
each dose until the pulse-rate is brought down to sixty or 
seventy per minute. One child two years of age required five 
drops and another seven drops every two hours to bring the 



14 



^p. cit., p. 402. 

2 New York Medical Record, 1888, 33, p. 627. 



210 diphtheria; its nature and treatment. 

pulse under control. When nausea results the close must be 
increased cautiously and omitted occasionally. Dr. Boyd re- 
gards this practice as unattended with danger. He accom- 
panies it with the use of other appropriate remedies. In proof 
of its value he refers to his successful employment of it in 
sixty-seven cases of unquestionable diphtheria, including* a 
fair share of malignant ones. He finds the most probable ex- 
planation of its efficacy in the view that by slowing the tired 
heart, it gives the rest which is so important to the recupera- 
tion of nerve-force. 

The Treatment of Diphtheria by Irrigation. 

Dr. G. Guelpa 1 advocates the treatment of diphtheria by 
the early, persistent, copious and very frequent washing of 
the parts which are affected by the disease or are threatened 
with its extension, whether in the pharynx, nares or else- 
where. The medicinal agent to be employed is a secondary 
consideration. Mild solutions of the chloride of iron have 
proved most successful in his hands, but he admits that other 
solutions, as of lime, carbolic acid or boric acid may be equally 
serviceable. The fountain-syringe or nasal douche may be 
used in the milder cases, but when the resistance to the passage 
of fluid requires it, more forcible methods should be resorted 
to. The irrigations should be practiced every quarter of an 
hour by day and every half -hour at night. Dr. Guelpa reports 
the successful employment of this method in a long series of 
cases at different periods. 

The Method of Treatment which has been Employed 
by the Author. 

In a paper read before the New York Academy of Medi- 
cine in March, 1876, 2 I presented statistics of one hundred and 

bulletin Gen. de Th6rap., 1887, pages 255, 313, 362. 

2 " Diphtheria and its Treatment, with Statistics of One Hundred 
and Seventy-nine Cases," Transactions of the New York Academy of 
Medicine, 1870, p. 286. 



TREATMENT. 211 

seventy-nine cases of diphtheria, one hundred and twenty-four 
of which had been visited by me in the North District of the 
Demilt Dispensary (the eastern part of the Twenty-first Ward 
of this city) in an epidemic of the disease which occurred in 
1875. That the epidemic in that locality had been especially 
severe was shown in the paper referred to and the subsequent 
discussion by statistics of the Board of Health and also by the 
testimony of other physicians. 1 

The results of the treatment employed in these cases were 
that in ninety-eight of the one hundred and twenty -four dis- 
pensary cases in which it was tested with some degree of fair- 
ness, though under very unfavorable conditions, there were 
ten deaths, or about ten per cent. In the remaining- fifty-five 
cases which were treated by the same method under more 
favorable conditions by the late Dr. E. J. Darken, Dr. W. E. 
Ballard and myself, there were only two fatal results. 

In a communication to the New York Medical Record 
(January 12, 1878, page 21) I reported the statistics of thirty- 
seven dispensary cases which had been treated by my assist- 
ant physicians, Dr. W. E. Bulla rd and Dr. D. C. Comstock, 
and myself in 1876 — the results being* that in thirty-two of 
them in which the treatment had been tested with some 
degree of fairness there had been three deaths, or, again, a 
little less than ten per cent. 

That these very favorable results might not be confounded 

*Dr. H. T. Hanks said: "Dr. Billington's success was truly remark- 
able, for he well knew the type of the disease as it had appeared in the 
Twenty-first Ward, having had, in his private practice during the last 
five years in that district, from twenty to thirty cases every year. He 
knew that many of the cases attended by Dr. Billington had been 
severe, and not a few malignant. Therefore when the large per cent, 
of recoveries was considered a cause must be looked for; and he be- 
lieved that two excellent reasons could be found for this satisfactory 
result. One was the kind of medicaments used locally and internally, 
and the other was the great care he bestowed in teaching the parents 
or nurses the proper manner of administering the remedies presented. 
This carrying out to the letter every little detail has had much to do, 
more than many have been led to suppose, in the cure of diphtheria. 11 



212 diphtheria; its nature and treatment. 

with the numerous reports of brilliant therapeutical triumphs 
based on inaccurate diagnosis or the exceptional mildness of 
the cases treated, I again in 1880 presented to the Academy a 
report l of equally good results obtained by the same methods 
of treatment in forty consecutive dispensary cases, the genu- 
ineness of which and the severity of a large proportion were 
kindly attested from personal examination either by Dr. A. H. 
Smith or Dr. W. T. White, most of the cases having also been 
seen by a number of other competent physicians. 

The treatment described in the first of the reports referred 
to consisted mainly in the use of the tincture of the chloride 
of iron, potassium chlorate, salicylic acid (in solution with the 
sulphite of soda), glycerine and lime-water, by frequent in- 
ternal administration, carbolic acid and lime-water by very 
frequent spraying, and the thorough cleansing of the nares in 
nasal diphtheria by syringing them with tepid salt water. 
Its most essential features are : (1) the most efficient possible 
local disinfection, (2) without irritation, (3) by frequent appli- 
cations, which are (1) so pleasant as not to arouse the opposi- 
tion of children nor unnecessarily to annoy and fatigue older 
patients, this being accomplished (5) by means of formulae and 
other details which were precisely stated and their importance 
insisted on. 

To avoid unnecessary repetition, these particulars and their 
application in the treatment of the various stages and forms 
of diphtheria will be subsequently stated in connection with 
such additional therapeutical measures as my own later ex- 
perience and the experience of others have shown to be most 
worthy of confidence. 2 Those which are now especially referred 
to may be found on pages 215, 216, 219, 220, 225 and 226. 

1 " Forty Attested Cases of Diphtheria, with Remarks on Diagnosis 
and Treatment," New York Medical Record, March 27, 1880, p. 333. 

! It is proper to state in this connection that Dr. A. Jacobi, in a 
paper entitled " Contributions to the Pathology and Therapeutics of 
Diphtheria,' 1 which was read before the New York County Medical 
Society in December, 1874, — more than a year before the reading of my 



TEEATMENT, 2.13 

Testimony to their successful employment of this mode of 
treatment has been given by many physicians either in pub- 
lished statements or in letters which have been received by 
me from all parts of this country and Canada. 

Some of these letters have borne witness to its efficacy 
not only in diphtheria as it occurs in this city, but also in 
malignant epidemics in distant localities. An especially in- 
teresting- and instructive statement to that effect from Dr. 
T. Clowes Brown, of Fredericton, New Brunswick, Canada, 
was published by me, with his permission, in the New York 
Medical Record, January 12, 1878, page 23. 

first paper — and published in the American Journal of Obstetrics, vol. 
vii., page 628, advocated the treatment of the severer forms of diph- 
theria by large and frequent doses of the tincture of iron ; the treat- 
ment of " simple tonsillar diphtheria " with " frequent small doses of a 
chlorate combined with lime-water, or tinct. ferr. mur. 3 ss — 3 ij- a 
day, and generally mixed with a little glycerine, principally for the 
purpose of keeping the remedy in longer contact with the diseased 
surface, if not for its own antifermentative effect ; " and the treatment 
of nasal diphtheria by thorough cleansing and disinfection of the nares 
by syringing them every hour or every half hour with " two to four 
grains of carbolic acid to the ounce of water, 1 ' or, " where there is no 
smell, lime-water, pure or somewhat diluted, for its solvent effect." 

This mention is made proper by the priority of Dr. Jacobi's publica- 
tion, and the coincidence in our therapeutical recommendations in res- 
pect to the drugs principally employed and the distinctive principles 
which I have above enumerated as 1, 2, and 3. 

In reference to these circumstances I made, in afoot-note to my first 
report above referred to, the following statement : — " There is, in my 
opinion, more essential and valuable truth in this little monograph " 
(Dr. Jacobi's) " than can easily be found elsewhere. It should be care- 
fully perused by all students of this much perplexed subject. It is 
proper to state that while I coincide with Dr. Jacobi's views in almost 
every particular I am not his ' follower,' except in the order of publi- 
cation. My own pathological conclusions and my present mode of 
treatment were independently arrived at (as many of my friends 
know) before his paper was written or I knew anything of its author's 
views." 

In the New York Medical Record, Feb. 23, 1878, page 158, I pub- 
lished a letter from the late Dr. E. J. Darken, who was House-Physician 
to Demilt Dispensary from 1869 until his death in 1886, which gave 
precise confirmation to the latter statement. 



214 diphthekia; its nature and treatment. 

The Treatment of the Early Stage of Pharyngeal 
Diphtheria. 

The special indications at this stage of the disease are local 
disinfection, the subduing- of inflammation and the reduction 
of fever. 

The patient should be put to bed in a clean, well-ventilated 
and yet sufficiently warmed apartment, from which unneces- 
sary articles of furniture have been removed. 

If the attack shows a tendency to severity and is attended 
with marked febrile symptoms, calomel should be given, either 
in a single purgative dose of from two to ten grains according 
to age, or, preferably in most cases, in divided doses of from 
one fourth of a grain to one grain mixed with sugar and placed 
upon the tongue every half hour, every hour or every two 
hours, until a purgative effect is produced. 

Ice in small pieces, or in the form of water-ices, is usually 
grateful to the patient and should be given frequently, and he 
should be permitted to drink ice-cold water freely if he craves it. 

Frequent cool sponging, especially about the head, face and 
neck, is often soothing and agreeable. If there is a marked 
tendency to glandular swelling, compresses frequently wrung 
out of ice-water, or ice-bags, may be applied over the affected 
region. 

If the patient is seen at the initial stage of the disease 
when the false membrane has not yet acquired much thickness 
or density, and if his age and the accessible location of the 
affection make it practicable, its abortive treatment may be 
attempted. The affected spot or spots, having been cleansed 
by spraying or irrigation and then dried by gently touch- 
ing them with absorbent cotton, may be carefully touched 
with a solution of the bichloride of mercury (toVo to too) D ^ 
means of a camel's hair brush or a soft swab applied with 
gentle pressure. This may be repeated every two hours (a 
mild antiseptic or solvent spray being frequently employed 



TREATMENT. 215 

in the intervals) if its effect seems to be good, but if, in spite 
of a few such applications, the local affection increases, its 
further use should be abandoned as only likely to aggravate 
the irritation. 

For the purpose of rapidly dissolving the false membrane 
solutions of pepsine, trypsin or papain may in some cases 
be advantageously employed at this stage of the disease by 
very frequent topical applications or spraying, as has been 
described on pages 167 et seq. 

Under the same circumstances the application of various 
caustic or astringent antiseptic agents, such as the nitrate of 
silver, the tincture of iodine, concentrated solutions of carbolic 
or salicylic acid, resorcin or chloral, which have been referred to 
in the preceding portions of this chapter and the mode of using 
them described, may doubtless in some cases arrest the disease 
at its outset. The favorable experience of some in the use of 
such agents has been stated, and also its limitations and 
dangers. It has formed no part of my usual treatment. My 
favorable experience in this use of Monsers solution or the 
tincture of the chloride of iron has been referred to, but even 
that may be ineffective and irritating. 

If the patient is old enough to permit it, the throat should 
be sprayed with some mild, solvent, antiseptic and antiphlo- 
gistic liquid as frequently as is practicable. I know of none 
which so admirably combines these qualities or has so good 
an effect under ordinary circumstances as the following mixt- 
ure: 1 

fy Acidi carbolici, ~n[ x. 

Aquas calcis, fl. 3 iv. 

M. S. — To be applied by spraying for some minutes every 
half-hour. 

This mixture has the important advantage of being more 
agreeable to the patient in its taste and after-effect than any 
other that I know of. Many children will permit its use that 
1 This formula was published by me in 1876. 



216 diphtheria; its nature and treatment. 

would oppose that of any other. The proportions are impor- 
tant, since the addition of a few drops more of the carbolic acid 
makes it pungent and disagreeable. That in a solution of this 
strength (xjg) carbolic acid is an efficient antiseptic and 
antiphlogistic has been shown on page 180. The valuable 
utility of lime-water has also been shown on page 165. The 
spray thus administered should be fine, as coarse sprays are 
unpleasant and irritating to diphtheritica! ly inflamed surfaces. 
Some atomizers which are now in very general use are ob- 
jectionable in the treatment of diphtheria for this reason. 




Fig. 10.— The Delano (No. 558) Atomizer. 

The Delano atomizer makes a fine spray, and is in every 
respect a convenient and suitable instrument. 

All atomizers which throw a fine spray are liable to be ob- 
structed by solid particles. Nurses should always be taught 
how to remove this obstruction by means of the fine wire 
which comes in the box with the atomizer, or with a bristle. 
When the Delano atomizer cannot be obtained, the Davidson 
instrument will serve a very good purpose, and has, indeed, 
some special advantages. 

The point of the atomizer should not usually be thrust into 
the throat of the patient, but should be held several inches 



TKEATMENT. 217 

from the open mouth. The spray is thus diffused over the 
whole surface of the palate and pharynx. In most cases in 
which the mouth is opened widely; the spray, if good aim is 
taken, reaches the pharynx freely. In some cases, however, 
it is necessary to carry the point of the atomizer further back 
over the tongue or to depress the tongue. The patient, when 
old enough, can usually be taught to do this, using a tongue- 
depressor in which the handle is at a right or obtuse angle to 
the blade. Nurses or parents must always be carefully in- 
structed in the proper use of the atomizer. 

Other mild antiseptic sprays may render valuable service 
in cleansing and disinfecting the mouth and throat, as, for in- 





DAVIDSOH RUBBER CO. DAVIDSON RUBBER CO. 

Fig. 11.— Davidson Anatomizer, No. 59. Fig. 12.— Davidson Anatomizer, No. 6. 

stance, solutions of permanganate of potassium (3 to 5 grains 
to the ounce), peroxide of hydrogen (one in four of water), 
bichloride of mercury (one in 4000 to 10,000), borax or boracic 
acid (one to three per cent, solution), salicylic acid (one in 500 
to 2000), etc. The special utilities and drawbacks of these and 
other valuable substances, and also the manner in which they 
may be employed, have already been stated. 

When the solvent ferments are applied by spraying, the 
point of the atomizer should be carried nearer the membrane 
to be dissolved than has been directed in other cases, that the 
solvent may be concentrated upon it. 

When the patient is too young to voluntarily permit the 
use of the spray (most children over three years of age can 



218 diphtheria; its nature and treatment. 

with tact be taught to take the pleasant one I have described) 
its use should not be attempted, and reliance must be placed 
on internal administration and irrigation. Mild antiseptic 
washes can be applied by the latter method when their use is 
indicated by the presence of viscid and offensive secretions in 
the mouth and throat. A hard -rubber syringe with a straight, 
slender, and smoothly rounded tip should be used. According 
to the valuable suggestion of Dr. Guelpa 1 it is not necessary 
to force the teeth open, but the tip of the syringe may be 
slipped between the teeth and the cheek, toward the angle of 
the jaw, and fluid injected will freely enter the mouth and 
pharynx behind the last molars. The utmost gentleness 
should be observed in doing this; it should not be repeated 
oftener than once in two or three hours, and never unless it is 
indicated by the presence of offending material which cannot 
be otherwise readily dislodged. I once shared the enthusiasm 
of Dr. Guelpa for the treatment of pharyngeal diphtheria by 
irrigation, but mj own further experience has been that while 
it has valuable uses, it may easily be made excessive, irritating 
and injurious. Warm salt-water (one drachm to the pint) or 
either of the mild antiseptic solutions just referred to is a 
suitable liquid to employ. 

The necessary cleansing of the throat may usually be ef- 
fected by the frequent internal administration of suitable 
remedies. 

Internal Medication. — Antipyretics. — It should be remem- 
bered that high fever at this stage of the disease in primary 
and uncomplicated cases is the concomitant of the inflamma- 
tion, and that its reduction is to be sought mainly by the em- 
ployment of the antiseptic and antiphlogistic measures which 
have now been referred to. When it is excessive and persist- 
ent I know of no antipyretic drug which will usually, according 
to my experience, yield such satisfactory results as the sali- 
cylate of soda. It may be given in doses of from two to fifteen 

J Op. cit. 



TREATMENT. 219 

grains in from a teaspoonful to a tablespoonful of water hourly 
or every two hours, according- to the age of the patient and the 
degree of fever, which doses may be increased, diminished or 
discontinued according- to the effect produced. With a suit- 
able diet its tendency to excite nausea will not often be mani- 
fested, and this may be further counteracted by adding- to each 
dose of the solution, when given, an equal quantity of cold 
Vichy or seltzer-water from a siphon -bottle. 

If the patient is robust, aconite, in doses of a fraction of a 
drop of the officinal tincture every half hour or oftener may 
sometimes be advantag-eously given for a short time at this 
stage of the disease. 

In case the salic3 r late of sodium is not tolerated or proves 
ineffective, antipyrin or antifebrin may be resorted to if its 
effect is urgently called for. The former may be given in 
doses of one and a half grains for every year of the child's age, 
every hour for three times, if necessary, and the latter in one 
fourth of these doses. I have never found the use of either of 
these drugs necessary except in diphtheria complicating or 
following scarlatina. Cold or warm sponging is often a useful 
and agreeable adjuvant. Quinine in antipyretic doses is rarely 
if ever appropriate in the early stage of diphtheria. 

In the great majority of cases I prescribe from the outset 
the chlorate of potassium and the chloride of iron. 

The utility of these drugs has been remarked upon on pages 
191 and 200. I have most usually prescribed them separately 
and in alternation in the following mixtures, 1 which are espec- 
ially appropriate and pleasant, and are usually readily taken 
by young children : 

No. 1. 
^ Potassii chloratis, . . . 3ij. — 3iv. 

Glycerini, fl. 3 ss. 

Aquae calcis, fl. % iijss. 

M. S. — A teaspoonful every hour. 
1 These formulae are identical with those published by me in 1876. 



220 diphtheria; its nature and treatment. 

No. 2. 
5- Tincfc. ferri chloridi, . . fl. 3 ij. — 3 iij. 

Glycerini, . . . . fl. 5 ij. 

Aquae, . . . ad. fl. § iv. 

M. S. — A teaspoonful every hour. 
Number two is given in half-hourly alternation with num- 
ber one. The weaker form should generally be used for chil- 
dren under three years of age. 

Or the two drugs may be thus combined : 

No. 3. 
r> Tinct. ferri chloridi, . . fl. 3 ij. — 3 iij. 

Potassii chloratis, . . , 3ij. — 3iv. 

Glycerini, fl. § ij. 

Aquae, .... ad. fl. 3 iv. 

M. Dose, a teaspoonful every hour, or every half -hour. 
The proportion of glycerine in these formulae is important 
— especially in the treatment of children — not merely for its 
demulcent and slightly solvent action, but mainly for its cov- 
ering the unpleasant acridity of the tincture of iron. 

The indications for discontinuing or increasing the doses of 
the tincture of iron have been pointed out on pages 201 and 202. 
When it is desired to increase them, this should be done, in the 
case of children, not by increasing the proportion of iron in 
the mixture, but by giving larger quantities of the mixture 
at a dose, and at shorter intervals. 

In some cases the use of the following mixture * at an early 
stage of the disease has seemed to have a particularly good 
effect in causing the rapid disappearance of membrane and 
reducing fever : 

P> Acidi salicylici, .... gr. x. — 3j. 

Sodae sulphitis, .... 3 ss. — 3 j. 

Glycerini, . . . . . fl. 3 ss. 

Aquae, . . . . . . fl. § ijss. 

M. S. — A teaspoonful every hour. 
1 This formula was published by me in 1876. 



TREATMENT. 221 

In this solution the antiseptic action of the salicylic acid is 
retained. It may be given instead of number one in half- 
hourly alternation with number two or number three. 

I have used it only during- the first two or three days of 
the disease. Number one is usually to be preferred in the case 
of young children. 

The bichloride of mercury may be given in connection with 
the treatment alrea.dy described. Its valuable effect is un- 
doubtedly the greater the earlier its use is beg-un. Its use is 
not indicated in mild cases of simple pharyngeal diphtheria, 
but is appropriate in the early stage of severe ones, and es- 
pecially in those in which laryngeal implication is threatened, 
either by the symptoms of the patient or the character of the 
prevailing epidemic. Its special utility and dangers and the va- 
rious modes of administering it have been referred to on pages 
175-177. It should, under the circumstances now considered, be 
given in doses of from T fo to -£$ of a grain, according to age 
and the severity of the disease, hourly, in at least a dessert- 
spoonful or a tablespoonful of water, milk or other beverage, 
or, preferably, in many cases, according to the experience of 
Dr. F. Huber, in half these doses half-hourly. Or, to avoid 
the unnecessary multiplication of doses, it may be added to 
♦formula number two or number three, as in the following pre- 
scriptions : 



Or, 



» 



Hydrargyri bichloridi, 


• gr. A — gr. t\ 


Tinct. ferri chloridi, . 


. fl. 3ij.— 3iij. 


Glycerini, . 


. • A- lij. 


Aquae, 


. ad. fl. 1 iv. 


M. 




Hydrargyri bichloridi, . 


• g" r - TO— g^ TO • 


Tinct. ferri chloridi, 


. fl. 3 ij. — 3 iij. 


Potassii chloratis, . 


3iv. 


Glycerini, 


. A- iij. 


Aquae, 


ad. fl. 1 iv. 


M. 





222 diphtheria; its nature and treatment. 

From one one-hundred-and-fiftieth to one one-hundredth of a 
grain of the bichloride is thus given in each teaspoonful. From 
one to two teaspoonfuls may be given hourly or half-hourly. 
It should preferably be given after the taking of food or drink. 
It cannot be too often repeated that its effect must be care- 
fully watched. Its use should not ordinarily be continued 
longer than three or four days. 

The strong evidence in favor of the valuable utility of the 
internal use of oil of turpentine has been referred to (see page 
194). That I have never employed it is due to my aversion to 
the use of measures in the treatment of diphtheria which are 
in themselves repugnant to the patient, and tend to produce 
nausea and disturbance of the digestive functions. Since it 
need usually be given only once a day it must be admitted 
that this objection thereby loses much of its force. Its special 
applicability seems to be, like that of mercury, rather to the 
more superficial or "fibrinous" rather than the deeper or 
" phlegmonous " form of the disease, and consequently to laryn- 
geal rather than pharyngeal diphtheria. Its most valuable 
effect is obtained from its early employment. The usual dose 
is from a teaspoonful to a tablespoonful in milk or emulsion. 

Various other remedies which have been referred to and 
the manner of employing them described on preceding pages 
of this chapter may be internally administered or locally 
applied at this stage of the disease with valuable effect, such 
as the cyanide or the biniodide of mercury (see page 177), 
sulphur, sulphurous acid, the hyposulphite of soda (pages 
182 and 183), iodine (page 185), iodoform (page 186), chloral 
(page 187), benzoate of sodium (page 190), peroxide of hydro- 
gen (page 188). 

One or another of these drags may doubtless in some cases 
be advantageously substituted for, or used in connection with, 
those which have now been especially recommended; but it is 
important to remember that the undue multiplication of rem- 
edies is particularly undesirable in the treatment of diphtheria, 



TREATMENT. 223 

and that from among" those which promise equal efficiency the 
one which is the most pleasant to the taste, the most accepta- 
ble to the stomach, and the least irritating- in its local effect 
should always be chosen. 

The diet in pharyngeal diphtheria should always consist of 
liquids or semi-solids. In the early stage of the disease it 
should be bland and simple, but nutritious. Milk has been my 
principal reliance in the great majority of cases, especially of 
children. It should be given, if possible, in the quantity of 
from four to six or eight ounces every two hours, but when 
only smaller quantities can be taken at once the frequenc}^ 
with which it is given must be proportionally increased. The 
physician must himself realize, and impress upon his patients 
and nurses, that the taking' of sufficient nourishment is a 
matter of prime and vital importance. It must be insisted 
on, however difficult and painful the effort of swallowing may 
be. The ingenuity and perseverance of the physician and the 
nurse must often be exerted to the utmost degree to effect this 
object. Even when the act of swallowing is most painful and 
repugnant to a child, he can usually be induced to take a little 
milk or other food after each dose of medicine or spraying of 
the throat or syringing of the nose. 

If milk is rejected by the stomach, the addition to it of 
lime-water in smaller or larger proportions, up to one-half, 
will often have a good effect. It may sometimes be advanta- 
geously alternated with beef, mutton or chicken-tea, or oyster 
or clam-broth. Though abundant nutrition is imperatively 
demanded in diphtheria, it is a serious error to overload the 
stomach with rich or concentrated foods during the febrile 
stage of the disease. In those cases in which milk is unfort- 
unately not tolerated, it may sometimes (though too rarely) 
be made available by peptonizing it, or koumyss may be a 
valuable resource, or the addition to milk of a little brandy or 
whiskey with or without sweetening may furnish the solution 
to the problem. When milk in no form is tolerated the reli- 



224 diphtheria; its nature and treatment. 

ance must be on farinacious gruels, meat- teas, juices, extracts 
and broths, beef-peptones, light custards, egg-nog, etc., the 
skill of the nurse in such devices being an important element 
of success. All other methods failing, nourishment by the 
rectum is indeed a resource — but a desperate one. 

The use of alcoholic stimulants is not usually indicated in 
the earlier stage of pharyngeal diphtheria, except under the 
circumstances and in the manner just referred to. In excep- 
tional cases in which the strength of the patient has been re- 
duced by previous illness, or in those malignant types of the 
disease in which septic poisoning with its depressing constitu- 
tional effects is evident from the first, the indication for their 
use is obvious and imperative. 

In order to economize to the utmost the strength of the 
patient, the administration of medicines and nourishment, 
which, in the treatment of diphtheria, is necessarily frequent, 
should be as systematic and regular as is practicable, and 
should be so arranged as to give the patient the longest possi- 
ble intervals of rest between them. The giving of medicine, 
the use of the spray, and the taking of nourishment should for 
this reason usually come in immediate succession (though 
sometimes in the opposite order), that the remainder of the 
half-hour may be appropriated to rest. But the patient must 
be promptly aroused at its termination, and this punctuality 
and regularity must be insisted on, except at night, Avhen an 
hour's undisturbed sleep may in most cases be occasionally 
permitted. In order to secure the cooperation of tender hearted 
parents in this apparent cruelty, it is important to strongly 
impress upon their minds its absolute necessity. 

The Treatment of Nasal Diphtheria. 

As nasal diphtheria is a very frequent complication of the 
more serious forms of the pharyngeal affection, its treatment 
should be considered before proceeding to that of the later 
stasre of the disease. 



TREATMENT. 225 

From the special danger of septic infection which attends 
this form of diphtheria, results the imperative indication of 
the cleansing- and disinfection of the nasal passages. It is 
essential that the physician realize that this is to be effected, 
not by the introduction into them of a little mildly antiseptic 
fluid, but by the most thorough removal from them of their 
poisonous contents which is practicable. It is also highly im- 
portant that this be accomplished with the least possible irri- 
tation, annoyance or fatigue. 

The instruments which may be employed for the purpose 
are the syringe or douche or the nasal atomizer. The use of 
the latter requires for its efficiency a coarse spray forcibly 
driven, the effect of which, in the treatment of diphtheria, is 
at once more irritating and less thorough than that of a 
stream from a syringe properly used. 

The syringing of the nares is necessarily somewhat un- 
pleasant to the patient, and usually provokes the violent re- 
sistance of young children. When bunglingly performed it 
may be most distressing, ineffective and injurious. 

The struggles of young children and the consequent danger 
of exhaustion and injury are best prevented by the well di- 
rected use of overmastering force combined with manual dex- 
terity and gentleness. Much experience has taught me the 
advantages of the following method : 

The assistance of two persons is required. The child is 
seated across the lap of one of these persons, who secures his 
hands with one of her own, and with the other holds a basin 
to receive the discharge. The other person stands behind the 
child, takes his head between the palms of her hands, and, 
leaning forward, holds it firmly against her breast. A third 
person who should, when possible, be a physician, can then 
easily make the injection into the child's nostrils without dan- 
ger of injury to them by its sudden movements. 

When the child is thus firmly held, or in the case of older 

patients, any small syringe will answer in careful and skilful 
15 



226 



diphtheria; its nature and treatment. 



hands; but under other circumstances one should be used 
which has a blunt and soft tip. It should also have a ring- in 
the handle, that it may be conveniently manipulated by one 




Fig. 13.— Manner of Holding a Child for Nasal Syringing. 

hand. The hard rubber half-ounce ear-syringe is in most re- 
spects a very suitable instrument; but its tip should either be 
cut off, as was suggested by Dr. S. W. Smith, 1 or, still better, 
should be padded, — a device which was recommended by Bre- 
1 New York Medical Record, 1886, 29, p. 354. 



TREATMENT. 



227 



tonneau. 1 This is easily done by surrounding- it with absorb- 
ent or other cotton and fastening- over this a perforated piece 
of rubber-cloth, oiled silk, chamois-leather or muslin, as is 




Fig. 14.— Hard Rubber Half -Ounce Ear-Syringe. (Reduced Size.) 




Fig. 15. — Ear-Syringe Padded. 

shown in figure 16. As this requires but a moment, the pad- 
ding may be changed after each syringing. 

A glass syringe expressly designed for this purpose, the 




Fig. 16.— Peerless Syringe, No. 4. 



nozzle of which is protected by a covering of soft rubber, is 
manufactured by R. Van der Emde, 323 Bowery, New York, 
and is called " Peerless Syringe, No. 4." 




Fig. 17.— Universal Syringe. 

An instrument which will serve very well in most cases is 
the " universal syringe " made by Tiemann & Co., which is en- 
tirely of soft rubber. 

1 Fifth Memoir. 



228 DIPHTHERIA; ITS NATURE AND TREATMENT. 

Warm salt-water (one drachm to the pint) is admirably 
suited to the purpose. The addition to it of bichloride of mer- 
cury (one grain to the pint) or of borax (one or two drachms 
to the pint) or of salicylic acid (four grains to the pint) is re- 
garded as an improvement by some. 

The fluid should be thrown with force enough to make it 
flow out, partly by the other nostril and partly by the throat, 
if the passages are pervious. If they are not so, more forcible 
injections may be employed, and these, with a little persever- 
ance, will usually succeed. Undesirable as these may seem, 
the removal of the obstructing mass should be regarded as 
imperative. Tearing away or boring through the membrane 
should not be resorted to on account of the great danger of 
its causing epistaxis. The very frequent application of pepsin, 
t^psin or papayotin by means of a medicine-dropper may be 
of service in very obstinate cases. 

The injections should be repeated on each occasion until the 
passages are thoroughly cleansed. From two or three to five 
or six applications to each nostril are usually sufficient to ac- 
complish this. 

When the operation is thus thoroughly performed, I have 
found by experience in many cases that its repetition from 
two to four times in the twenty-four hours is usually sufficient 
to secure the desired effect. Its repetition with unnecessary 
frequency is to be deprecated, since it is more or less unpleas- 
ant and irritating and consequently fatiguing, even to adults, 
from the especial susceptibility of the nasal mucous mem- 
brane, and much more so to children who have to be coerced, 
and in the treatment of bad cases of this disease the strength 
cannot be too carefully economized. When it is only partially 
or imperfectly done, as it must be by only a single injection 
into each nostril on each occasion, as is practiced by some, it 
of course becomes necessary much of tener. 

When the syringing of the nares has to be entrusted to 
nurses, they must be carefully instructed by the physician as 



TREATMENT. 229 

to all its details, such as the angle (more nearly horizontal than 
perpendicular) at which the syringe is to be introduced, etc., 
and even then he will too often have the pain of finding- that 
it has been very imperfectly or badly executed. 

I have dwelt at such length on the details of nasal syring- 
ing, because, whatever may be thought of the utility of vari- 
ous other therapeutical measures in the treatment of diph- 
theria, there can be no doubt' that upon this one the saving of 
many hundreds of lives every year directly depends. If it is 
neglected in severe cases of nasal diphtheria the patient is 
almost sure to die; if it is efficiently performed the greater 
proportion recover. 

The Treatment of the Later Stage of Pharyngeal and 
Nasal Diphtheria. 

The special indications for treatment in the later stage of 
diphtheria are : 

1. To continue local measures for antiseptic effect. 

2. To counteract the effects of constitutional poisoning. 

3. To sustain the strength of the patient. 

4. To appropriately deal with complications which may 
arise. 

In a large majority of all cases which have been treated 
early and efficiently by the methods already described, the 
disease will have been so favorably modified by them, in limit- 
ing the extension and moderating the intensity of the local 
affection and preventing or minimizing the absorption of 
poison, that they may be without difficulty conducted to com- 
plete recovery, after a duration of from four to twelve days, 
by the continuance of the mild solvent and antiseptic local 
treatment, the internal administration of chloride of iron and 
the chlorate of potash and the measures for nutrition and 
rest which have been recommended. 

In a much smaller proportion of cases, which, however, 



230 diphtheria; its nature and treatment. 

varies considerably in different epidemics, in which the disease 
is from the outset of especial severity or malignancy, and of 
the deeply infiltrated or " phlegmonous-septic " type, and in 
other cases in which treatment is begun only at an advanced 
stage of the malady, an arduous and prolonged conflict with 
it is yet to be waged. 

At this stage in such cases, hyperpyrexia has usually dis- 
appeared along with the acute intensity and tendency to rapid 
extension of the local inflammation, and evidences of constitu- 
tional or septic poisoning present themselves. 

It is of the utmost importance that the physician realize 
that his chief resource in order to prevent the system being 
f atalty overwhelmed by this poison is in diminishing the amount 
introduced into the circulation by the most thorough possible 
cleansing of the sources from which it is absorbed. 

The means for effecting this object, namely, washing them 
with suitable antiseptic solutions, applied by internal admin- 
istration, spraying and irrigation, have already been described. 
If they are neglected or only inefficiently employed, it will too 
often be found that no amount of stimulation or other internal 
medication will avail to save the patient. 

I have in many instances, after beginning the treatment of 
a case at this stage of the disease, seen the pallor and sallow- 
ness of the skin soon replaced by natural tints, apathy and 
somnolence disappear, nausea and vomiting cease, the dull 
eye become bright, the feeble and flickering pulse become full 
and regular, simply or mainly from the effect of these meas- 
ures. In some of them heroic stimulation and medication, 
previously employed under other direction, had failed to pro- 
duce any favorable effect. 

This good effect is often manifested in spite of the persist- 
ent presence of quite extensive membranous deposits. In this 
case the effect of the antiseptic washes is doubtless exerted 
not only by their removing from all the surfaces much poison- 
ous material which would otherwise be absorbed, but also by 



TREATMENT. 231 

their penetrating- in some degree the false membrane itself, 
and thus causing, by osmotic action and the interchange of 
fluids, more or less diminution, dilution and disinfection of the 
noxious products of the disease lying beneath it. 

The denser and thicker the false membrane is, the less, of 
course, can the latter effect be produced. Hence the difficul- 
ties in the way of thorough local disinfection are often very 
great and sometimes insuperable, especially in the cases of 
young children. When masses of thick membrane oppose it, 
these may, if accessible, be softened and thinned by the fre- 
quent application of the solvents which have been referred to, 
or in some cases by the careful application of such agents as 
Monsel's solution, which tend to shrivel and disintegrate them 
and restore tone to the relaxed and infiltrated tissues. 

Adenitis, in such cases, often presents a serious obstacle to 
antiseptic endeavors, since the diphtheritically inflamed glands 
are in themselves inaccessible foci of infection. In the treat- 
ment of this complication, it must still be remembered that 
the first indication is by the local antiseptic measures just re- 
ferred to, to prevent or limit the absorption of more poison 
through the lymphatics into the glands. The adenitis itself 
may be let alone or treated with cold or warm applications. 
If there is febrile temperature and the adenitis is increasing, 
ice-bags may be applied. If the adenitis is no longer increas- 
ing and is not especially annoying, it is best let alone. If, 
in the later stage of the disease, the tumors are large and 
painful or show a tendency to suppuration, they should be 
treated with warm poultices. The application of ointments 
of iodine or iodoform or mercury is probably useless. All irri- 
tant applications to the skin should be avoided. The applica- 
tion of the linimentum belladonna?, mixed with half the quan- 
tity of glycerine, has in some cases seemed to me to have a 
soothing and beneficial effect. 

The second and third indications above referred to, though 
distinct, are yet to be mainly fulfilled by the same means, 



232 DIPHTHERIA; ITS NATURE AND TREATMENT. 

namely, the chloride of iron, abundant nourishment, alcoholic 
stimulants and appropriate tonics. 

. The pre-eminent utility of the chloride of iron in enabling 
the system to withstand the effects of diphtheritic poisoning- 
has been remarked upon on page 200. When this condition is 
present it must be freely administered. Formula number two 
(page 220) should be used, and of this mixture from one to two 
teaspoonfuls may be given every half-hour, according to age 
and tolerance, or in very urgent cases, every twenty minutes. 

The maintenance of abundant nutrition is of primary im- 
portance. Not only is this essential for sustaining the strength, 
but it is practically an antiseptic measure, since the less is the 
supply of nourishment to the system, the greater is the ab- 
sorption of poison. If milk is freely taken it is still the most 
suitable food, but, in view of the tendency to the failure of 
strength, more stimulating articles may often be advanta- 
geously added to the dietary. Among the most useful of 
these is the freshly expressed juice of underdone beef in small 
quantities, or Valentine's beef-juice. Concentrated and pre- 
digested food-preparations, such as the" various "beef-pep- 
tones," "liquid peptonoids," etc., may often be serviceable. 
Other suitable additions to the dietary have been already re- 
ferred to (page 223). Discretion in the administering of rich 
or concentrated foods is, however, very important, since the 
digestive function too often shares in the general enfeeble- 
ment, and may be easily deranged. Excessive or injudicious 
feeding may thus defeat the very object for which it is em- 
ployed. 

Alcoholic stimulants are required in most bad cases at this 
stage of the disease, and must in many cases be given freely. 
Their utility in the treatment of diphtheria, and its limitations, 
have been remarked upon on page 203 et seq. 

Valuable assistance in promoting appetite and digestion 
and combatting the tendency to debility which attends the 
later stage of diphtheria and the period of convalescence, may 



TREATMENT. 233 

be obtained from various tonics, especially the preparations 
and alkaloids of cinchona bark and nux vomica. Among 
standard preparations, the compound tincture of cinchona or 
the elixir or wine of calisaya, the elixir of pepsin, bismuth and 
strychnine, the elixir of the phosphates of iron, quinine and 
strychnine given in doses appropriate to the age, have obvious 
applications and utilities in this as in other diseases. The 
same in true of quinine in tonic doses of from one fourth of a 
grain to two grains three or four times a clay. I have been 
enabled to obviate the important difficulty arising from its 
unpleasant bitterness in many cases of young children by the 
use of chocolate lozenges, each of which contains one grain of 
the tannate of quinine, and which are prepared by Caswell 
and Massey of this city. They are generally liked by children. 
Quinine may also in many cases be advantageously adminis- 
tered to young children in rectal suppositories. Two or three 
grains of the sulphate of quinine in five or six grains of the 
butter of cacao in each suppository is a convenient size. Their 
introduction is facilitated by the use of a small hard-rubber 
tube-and-piston depositor which is made for the purpose. 

In conditions of extreme debility with accompanying pro- 
gressive heart-failure, alcoholic stimulants given freely, but 
with careful regard to the limit of their tolerance by the stom- 
ach, are our most valuable resource. If the pulse is feeble and 
rapid or irregular, the tincture of digitalis may be given in 
small doses, the effect of which is to be carefully watched, and 
strychnine in small doses (from -^ to -^ of a grain) may be 
useful. Except in the case of very sensitive children, to whom 
the shock and fright caused by the operation may be injurious, 
the hypodermic administration of either of these remedies is 
to be preferred on account of its more prompt and certain 
effect. Freshly made coffee in teaspoonful doses may also be 
serviceable. Fresh beef -juice in similar doses may have a val- 
uable stimulant effect. The predigested foods already referred 
to may be useful aids in maintaining nutrition. The great 



234 diphtheria; its nature and treatment. 

importance of the most abundant supply of fresh air should 
never be forgotten. If such bulky and unpleasant drug's as 
musk are employed in the case of children, their administra- 
tion by enema is for obvious reasons to be preferred. The 
patient must be strictly kept in the recumbent posture and 
all unnecessary exertion and agitation avoided. 

The mere fact of the occurrence of albuminuria does not 
ordinarily call for special treatment. Indeed, since its pres- 
ence at this stage is usually the result of the irritation of the 
kidneys by the noxious products of the disease which have 
been absorbed into the general circulation, the indication which 
it furnishes is the continuance of the antiseptic and sustaining 
measures which have been already referred to. 

The same indication remains equally in force in those 
graver forms of the affection in which the urine more or less 
suddenly becomes scanty and dark and of high specific gravity, 
and contains a large percentage of albumin with casts and 
blood-corpuscles, with accompanying febrile symptoms and 
marked evidences of ursemic poisoning; but the complication 
itself is so liable to be rapidly fatal, that prompt measures 
must be employed for its removal. These measures are the 
same as when nephritis occurs in other conditions, but the 
weakness and prostration of the patient often make their 
energetic employment impracticable. In cases in which this 
weakness and prostration are not too marked for its use to be 
admissible, and especially if the bowels are constipated, purga- 
tion by a single dose of from one to five grains of calomel or 
by doses of a quarter of a grain given in frequent succession 
or by a grain of calomel with from six to ten grains of com- 
pound jalap powder to a child from three to five years old, or 
to feebler patients a wine-glassful of citrate of magnesia re- 
peated every hour or two if necessary, will often have a 
promptly favorable effect. 

Dry cups may be applied over the kidneys. 

The mode of producing at once a revulsive and diaphoretic 



TREATMENT. 235 

effect which I have found especially valuable in many cases of 
scarlatinal and diphtherial nephritis is to envelop the entire 
circumference of the loins and abdomen with a warm flax-seed 
poultice, which should be frequently renewed. 

The use of the ordinary diaphoretic and diuretic drugs is 
often impracticable on account of the tendency to nausea and 
vomiting- and the weakness of the patient. Digitalis may be 
given in the form of the infusion with citrate or acetate of 
potash if the stomach will retain it ; but otherwise in the form 
of the tincture, of which a suitable dose may be added to other 
medicines or administered hypodermically. 

Throughout the entire treatment of a case of diphtheria, 
great importance should be attached to maintaining the strict- 
est cleanliness of the patient himself and all his surroundings. 
His clothing and the bed-linen should be frequently changed 
and thorough disinfection of all vessels and utensils practiced, 
as directed in the chapter on prophylaxis. The room should 
be frequently and thoroughly aired. In order that the patient 
may not take cold while this is being done the alternate use 
of two adjoining rooms, when practicable, is an advantage in 
the colder season of the year. In some persistent cases the 
removal of the patient to a fresh apartment has seemed to 
exert a favorable influence. When the climate and other cir- 
cumstances make it practicable, the patient may sometimes 
be advantageously kept in the open air. 

The Treatment of Laryngeal Diphtheria. 

Medical Treatment in reference to laryngeal diphtheria is 
(1) preventive and (2) mitigating or curative. 

The liability of pharyngeal and nasal diphtheria to extend 
downward into the larynx, especially during the first few 
days, suggests the employment of measures in their early 
stage which may diminish that liability. These measures are : 

1. Those which tend to moderate the intensity and check 
the spread of the primary affection, since that result diminishes 



236 DIPHTHERIA; ITS NATURE AND TREATMENT. 

the probability of its extension into the larynx. These meas- 
ures have already been referred to. 

In the treatment of young" children all irritating" applica- 
tions and unpleasant remedies which cause crying' and strug- 
gling are especially contra-indicated,, since in such crying and 
struggling the irritating drug or diphtheritic matter is liable 
to be drawn into the larynx and favor the extension of the 
disease thither. 

2. Those which have a special tendency to prevent laryn- 
geal implication. — These measures are the inhalation of un- 
irritating antiseptic and astringent spray or vapor and also 
the internal use of certain drugs, especially mercurials and the 
oil of turpentine. These have also been referred to in connec- 
tion with the treatment of pharyngeal diphtheria. 

My own experience of the valuable effect of this use of the 
spray of carbolic acid and lime-water was stated in my first 
published report as follows : " Out of fully one hundred cases, 
including Dr. Darken's, in which the spray of carbolic acid and 
lime-water has been employed, there has been no instance of 
the subsequent occurrence of serious laryngeal complication, 
though in several of them it has been threatened by croupy 
cough, hoarseness and aphonia. That the inhalation of the 
spray has acted as a preventive in some of these is, I think, 
not improbable." Much subsequent experience of myself and 
others has confirmed me in this belief. The composition of this 
spray and the mode of using it have been stated on page 215. 

In the case of children too young to take the spray, the in- 
halation of antiseptic vapor, especially that of the oil of tur- 
pentine, may be employed as a preventive. 

Mitigating and Curative Measures. — The earliest possible 
recognition and treatment of laryngeal diphtheria is of great 
importance. The physician should pay careful attention to 
the slightest huskiness or hoarseness of the voice which may 
be its premonitory symptom. Many cases may doubtless be 
cut short or prevented from becoming severe when properly 



'TREATMENT. 237 

treated at their first slight beginning's, which would later 
defy all remedies. 

When the symptoms of laryngeal diphtheria are present 
the measures to be employed depend somewhat upon their 
gravity and the rapidity with which they increase. In esti- 
mating at the outset the probability of their becoming severe, 
the fact elsewhere referred to may be remembered, that as a 
general (though not invariable) rule this probability is greater 
the earlier the laryngeal affection appears. 

The remedies which maybe employed comprise mercurials, 
solvent, antiseptic and astringent sprays and vapors, steam, 
expectorants and emetics. 

The mildly solvent and antiphlogistic effect of the pleasant 
spray of carbolic acid and lime-water has been found sufficient 
in quite a number of cases of slight or moderate severity. In 
my first paper 1 I reported in detail a case of unquestionable 
laryngeal diphtheria accompanying pharyngeal diphtheria in 
a child of four years, in which very serious and constant 
dyspnoea in both acts, with marked depression over the clavi- 
cles with inspiration, continued for eleven days, but which 
finally recovered without operation under the very frequent 
use of this spray. I have since seen several almost as striking 
cases of recovery under the use of the same remedy. 

The fact has been referred to that the solvent power of 
lime-water may be increased by adding to it another alkali, 
as, for instance, one per cent, of liquor potassae, or bicarbonate 
of soda, but at the expense of making its frequent and contin- 
ued use somewhat irritating to mucous membranes. Hence 
this method should be employed only where the necessity for 
a rapid solvent effect is urgent. 

The testimony in favor of the utility of trypsin and papay- 
otin as solvents of false membrane has been referred to, and 
the manner of employing them has been described on pages 
168 and 169. The solution should be carefully prepared by 
1 Transactions of N. Y. Academy of Medicine, 187(3, p. 210. 



238 DIPHTHERIA; ITS NATURE AND TREATMENT. 

rubbing the solvent in a mortar and, if necessary, afterward 
straining it, so that a fine spray may be used, and the solu- 
tion should be of the most unirritating character, so as not 
to excite cough and dyspnoea. 

It must be remembered that the spray can effectively 
reach the interior of the larynx only by being carried thither 
by the inspired air. The atomizer should therefore be held 
at some little distance from the mouth (which must be 
widely opened and the tongue depressed if necessary) so 
that the atomized particles, having lost their first impetus, 
may be carried downward in the current of the breath. This 
necessitates some moistening of the face with the spray, but 
even quite young children, with proper management, soon 
become accustomed to it and tolerate it. 

The same principle is applied in instruments called " nebu- 
lizers," or " vaporizing atomizers/' which have recently been 
brought into use, by which the particles are so suspended in 
the air as to be readily carried into the air-passages by the 
breath. Liquids, in order to be " nebulized/' require to be given 
a certain consistency by the addition of not less than one- 
eighth part of glycerine, or some similar substance. In the 
limited opportunities which I have as yet had for experiment- 
ing with these instruments I have not been able to satisfy 
myself that the amount of medicated fluid which can be so in- 
troduced is sufficient to be effective in the treatment of croup, 
but I think it not improbable that they may be found to have 
some utility. One of the best of them is the "vaporizing 
atomizer, No. 169," made by Codman and Shurtleff. 

Though the use of the hand -atomizer has obvious advanta- 
ges in point of convenience, yet in most cases in which it is 
practicable the application of spray together with warm 
vapor, by means of the steam-atomizer, is to be preferred. 

Unfortunately, the impracticability of applying spray to 
very young children precludes its employment in a considera- 
ble proportion of our worst cases. The evils attending its ap- 



TREATMENT. 



239 



plication by force more than counterbalance its benefits. I 
have made mam^ attempts to overcome this difficulty by vari- 
ous expedients, but never with satisfactory results. 

In cases in which the efficient use of spray is impracticable, 




Fig. 18.— Vaporizing Atomizer. 



and in most cases whicn are serious or show a tendency to 
become so, the inhalation of steam should be resorted to. The 
most efficient method of doing* this is the construction of a 
tent over the crib or bed with blankets and barrel-hoops or 




Fig. 19.— Steam Atomizer. 



other supports. There should be an opening- in one side of the 
tent for ventilation. The air within the tent may be kept 
saturated with warm vapor by means of a tube from a croup- 
kettle, which should be placed outside of it. 



240 diphtheria; its nature and treatment. 

The air in the tent being- thus maintained at an equable 
warmth, and draughts being excluded, the room can safely be 
ventilated by opening the window or otherwise, and the evil 
effect of the impairment of the air by the burning- of the alco- 
hol or other combustible employed, be in great measure ob- 
viated. 

In the absence of a croup-kettle, an ordinary tea-kettle and 
a gas or oil-stove may be made to answer the purpose. When 




Fig. 20.— Croup-kettle. 



india-rubber tubing cannot be obtained, a substitute may be 
made with stiff paper or pasteboard surrounded with some 
fabric, as a roller-bandage. 

Or a small room in which boiling water can be kept con- 
stantly running from the pipes, or in which steam-pipes can 
be tapped, may be utilized. 

The solvent effect of lime on the false membrane may be 
additionally obtained by putting pieces of quick-lime into 
the water in the croup-kettle every hour or two. It should 



TKEATMENT. 241 

always be remembered that the boiling of lime-water for this 
purpose, which is often recommended, is useless. 

The vapor may be made the vehicle of various drugs for 
their antiseptic or specific effect. The most valuable of these 
is the oil of turpentine. This may be added, a tablespoonful 
at a time, to the water in the croup-kettle every hour or two, 
or it may be volatilized in the air of the room by the method 
of Dr. Delthil, described on page 197. Its good effect may 
perhaps be aided by adding a teaspoonful or two of the oil of 
eucalyptus. 

The abundant evidence of the special utility of the bi- 
chloride of mercury in the treatment of this form of diphtheria, 
and the importance of its early employment, have been already 
referred to. When the drug is given to avert threatened 
laryngeal stenosis, the indication is, of course, to bring the 
system of the patient as rapidly under its influence as is con- 
sistent with safety. In such circumstances it is important to 
know that the tolerance of it is, in many children, remarkably 
great. Dr. Jacobi states l that " a baby a year old may take 
one-half grain every day many days in succession with very 
little if any intestinal disorder and with no stomatitis/' if it 
be given in proper dilution. This is equivalent to one forty- 
eighth of a grain every hour. Dr. O'Dwyer, who has employed 
this remedy in many cases of croup, and regards it as very 
valuable, begins with about one eightieth of a grain at that 
age, and gradually increases to the dose mentioned by Dr. 
Jacobi, if the case threatens to run a rapid course. He very 
seldom begins at any age with more than one fiftieth of a 
grain hourly, and increases or not according to the progress 
of the case. He also attaches much importance to proper 
dilution, having known one fiftieth of a grain dissolved in two 
drachms of water to give rise to severe pains in the stomach, 
which did not recur when the dilution was increased to half 
an ounce. He has yet to see any serious gastric or intestinal 

1 Loc. cit. 
16 



242 diphtheria; its nature and treatment. 

disturbance, or more than the slightest amount of stomatitis, 
from the sublimate administered in this manner, even when 
continued so long- as a week. A moderate looseness of the 
bowels is, according to his experience, easily controlled by the 
addition of a mild opiate, but directions should always be left 
with the attendant to suspend the medicine on the occurrence 
of any severe diarrhoea or much pain in the stomach or bowels. 

The advantage, when large doses are being administered, 
of giving them in half the quantity every half -hour, has been 
referred to on page 221. 

The administration of mercury by inunction, by hypodermic 
injection, and by volatilization and inhalation, has been re- 
ferred to on pages 177, and 178. 

The internal administration of the oil of turpentine has 
also been referred to on pages 195 and 222. 

Emetics have a well established utility in the treatment of 
croup, whether catarrhal or diphtheritic; but they should be 
used with discretion — not too often, nor usually in the later 
stages of the disease, nor ever in conditions of marked weak- 
ness, systemic infection or cyanosis. The3 T are beneficial 
mainly by their expectorant effect, producing increased secre- 
tion of mucus and the expectoration of that which has accu- 
mulated, and sometimes causing the throwing off of membrane 
which is only loosely attached. They usually give temporary 
relief, at least. 

While the syrup of ipecacuanha, or of ipecacuanha and 
squills, in doses of half a teaspoonful to a teaspoonful, or sul- 
phate of copper in doses of two to five grains, repeated, if 
necessary, in fifteen minutes, will render excellent service in 
many cases, the yellow sulphate of mercury is usually to be 
preferred as being most reliable, prompt and thorough in its 
action. The dose is from three to five grains. To much pre- 
viously published testimony to the especial utility of this 
emetic I am permitted to add the following statement by Dr. 
O'Dwyer: "In what may be called sthenic cases, when the 






TREATMENT. 243 

dyspnoea becomes urgent and abiding", or, in other words, when 
it is time to operate, prompt vigorous emesis, such as is pro- 
duced by the yellow sulphate of mercury, often gives marked 
relief, which sometimes lasts long enough to render a repeti- 
tion of the vomiting safe, if stimulants and nourishment be ad- 
ministered in the interim. By this means I have succeeded in 
getting a good many cases through, especially those that had 
been placed on the bichloride treatment at the commencement 
of the disease, that would otherwise have required intubation." 

In asphyxia emetics usually fail to act. In this condition 
it is said that the emetic action of apomorphia is not interfered 
with. It should be freshly prepared. Its hypodermic admin- 
istration in doses not to exceed one centigramme is recom- 
mended by Munoz. 1 In this condition, however, it need hardly 
be said that not an emetic, but intubation or tracheotomy, is 
the remedy which should be employed. 

In those cases in which a frequent, harsh and painful cough 
is accompanied with recurrent paroxysmal dyspnoea, an opiate 
is useful — as, for instance, Dover's powder or its liquid equiva- 
lent, the tinct. ipecacuanhse et opii of the Pharmacopoeia, in 
doses proportionate to the age and the amount of pain and 
irritation. The good effect of the remedy may be aided by the 
application of warm flax-seed poultices, to which a small pro- 
portion of mustard has been added. 

The remarks made as to the importance and the methods 
of maintaining nutrition in other forms of diphtheria are 
equally applicable in reference to this one. In proportion as 
the strength is taxed by the persistent dyspnoea, and in pro- 
portion as the amount of nutritious food which the patient 
will take is diminished, the giving of alcoholic stimulants be- 
comes the more necessary, and is consequently required in 
most cases of any severity or duration. After tracheotomy 
or intubation, this necessity usually becomes, from the latter 
of the reasons referred to, even more imperative. 
J E1 Prog. Ginecol., July 10, 1887. 



244 diphtheria; its nature and treatment. 

Laryngeal diphtheria may doubtless be prevented or cured 
by the early employment of the measures which have now 
been referred to, in a considerable proportion of cases; but 
since its initial symptoms, such as huskiness of the voice and 
croupy cough, even when they occur in connection with other 
forms of the disea se, can by no means be regarded as pathog- 
nomonic signs of a pseudo-membranous affection of the larynx, 
these results cannot be statistically estimated. It must be 
admitted that in a large proportion of all cases of unquestion- 
able laryngeal diphtheria, medical treatment alone is inade- 
quate to prevent a fatal termination. This proportion has 
been estimated by Morell Mackenzie 1 at ninety per cent. 
Sanne 2 states that in 2809 cases of croup which have been en- 
tered at the Hopital Sainte Eugenie, 240, that is 1 in 13, have 
recovered without operation. 



Tracheotomy. 

When the respiration is so seriously interfered with in 
laryngeal diphtheria that asphyxia is imminent, operative in- 
terference is usually the onry resource by which the life of the 
patient can be saved. There can be no doubt that intubation 
will in the future, to a greater or less extent, take the place of 
tracheotomy in fulfilling this indication; but since that opera- 
tion, as it is now practiced, with its general and special indica- 
tions, will be subsequently treated of by its inventor, Dr. 
Joseph O'Dwyer, I shall confine my remarks to tracheotomy. 

The utility of tracheotomy as a means of saving life is, in a 
general sense, sufficiently illustrated by comparing with the 
estimate just quoted of the ratio of recoveries in cases of 
membranous croup not operated upon, the following statistics 
of the recoveries in " all available reported cases " in which 
tracheotomy had been performed previous to 1887, as compiled 

1 Op. cit., p. 89. 2 Op. cit, p. 490. 



TREATMENT. 



245 



in an interesting and instructive paper by Drs. Lovett and 
Munro : x 





Total. 


Recovered. 


Died. 


Per Cent 
Recovered. 


German authors .... 
German hospitals .... 

British authors 

French authors 

Various countries .... 
American authors .... 


5795 
3063 
433 
9242 
1993 
1327 


1851 
939 
138 

2242 
657 
308 


3944 
2124 
295 
6834 
1336 
1019 


31 
30 
31 
24 
32 
23 




21,853 


6135 


15,552 


28 



Tracheotomy has, in many considerable series of cases, 
been attended with a much larger proportion of recoveries, as 
is illustrated in the following" examples : 



Per cent, of 
Operations Recoveries Recoveries 



Surgical Clinic in Konigsberg, 

1878-1882, (Plenio 2 ) 123 60 
Tracheotomies by H. Ranke, 3 Munich, 

April 1, 1878, to Sept. 1, 1885. . 54 34 

Tracheotomies by A. Caselli 4 . . 132 82 

Ibid (with improved instruments) . 18 13 



4-8J 



63 



72- 3 - 
i/0 i o 



The results of tracheotomy differ widely according to a 
great variety of circumstances, of which the following are 
especially important : 

1. The methods and skill employed in the operation and 
the after-treatment. 

2. The age of the patient. — The results of tracheotomy are 
very unfavorable in infants, and in older children improve in 



1 "A Consideration of the Results in 327 Cases of Tracheotomy Per- 
formed at the Boston City Hospital from 1864 to 1887; by Robert W. 
Lovett, M.D., and John C. Munro, M.D.," American Journal of the 
Medical Sciences, 1887, vol. xciv., p. 160. 

2 Jahrb. f. Kinderh., Bd. xxii., H. 4. 
3 Jahrb. f. Kinderh., Bd. xxiv., p. 225. 
4 G-az. Med. Ital. Loinb., 1887, p. 198. 



246 



diphtheria; its nature and treatment. 



proportion to the age. Dr. Gust a v. Chagin 1 has collected the 
statistics of 977 operations in infants, of whom only 15 per 
cent, recovered. 

M. Sanne 2 thus states the results of tracheotomies at the 
Hopital Sainte Eugenie according to the age of the patients: 

Age. Cases. Recoveries. Percent. 

1 to 2 years . . 653 

3 " 5 " . . . 1298 

6 " 10 " ; . . 335 

11 « 15 " . . . 26 

Dr. H. Settegast 3 has tabulated the results of tracheoto- 
mies in the Krankenhause Bethanien (1861 to 1877) as follows: 



88 


13.6 


285 


21.9 


127 


37.8 


9 


32.3 





A 


.ge. 


2 to 


3 


years, 


3 " 


4 


(C 


4 " 


5 


(( 


5 " 


6 


(( 


6 " 


7 


a 


i 


8 


a 


8 " 


9 


a 


9 " 


10 


a 



Cases. 


Recoveries. 


Per cent. 


93 


22 


23.65 


165 


. 47 


28.45 


175 


54 


30.85 


107 


39 


35.45 


90 


34 


37.77 


59 


17 


38.86 


24 


11 


45.83 


15 


6 


40 



3. The type, as to fatality, of the prevailing disease. — This 
has been remarked by most writers on the subject. Lovett 
and Munro 4 state that the tracheotomy death-rate at the 
Boston City Hospital from 1881 to 1885 inclusive, varied by 
the month in the closest correspondence to the mortality per 
cent, of diphtheria for the same time in the whole city of 
Boston. 

4. The season of the year. — The writers just quoted from 
state that during the same five years (1881-1885) not twenty 
per cent, recovered of those operated upon in December, Jan- 
uarj 7 , February and March, "while from the latter month the 

] Archiv. f. Kinderh., Bd. iv. 2 Op. cit., p. 485. 

3 Langen beck's Archives, Bd. xxii., p. 882. 4 Loc. cit. 



TKEATMENT. 247 

recovery rate rises until July, when about sixty per cent, of 
all cases operated upon get well." 

M. Sanne states that the results of all the tracheotomies 
at the Sainte Eugenie up to 1876 give the following ratios of 
recoveries: for June, 1 to 3.31; for August, 1 to 3.56; for No- 
vember, 1 to 7.19; for December, 1 to 6.18; and for January, 
1 to 5.04. 

5. The stage of the disease. — It is a well-established fact 
that the prospect of the successful result of tracheotomy is 
the greater the earlier it is performed after the nature of the 
disease requiring it is recognized. This is further illustrated 
by the following figures in the article of Lovett and Munro 
from which I have previously quoted: 

The time is reckoned from the beginning of obstructed 

respiration. 

Day of Operation. Cases. Recoveries. Per cent. 

1 . . . . .123 40 32.5 

2 86 24 28.0 

3 33 8 25.3 

4 7 1 14.0 

6. The condition of the patient. — The most favorable re- 
sults from tracheotomy may be expected when the previous 
health of the patient has been good and the disease is primary 
and uncomplicated. The prospect of success is generally bad 
in secondary diphtheria, and when the laryngeal affection ac- 
companies a malignant or septic form of diphtheria, or is at- 
tended with pseudo-membranous bronchitis, broncho-pneumo- 
nia or other grave complications. 

These unfavorable conditions are regarded by some as 
contra-indications to the operation. This may doubtless in- 
sure the avoidance of many bad results. Dr. J. Lewis Smith 
states that a surgeon of this city (Dr. A. R. Robinson) who 
carefully selects his cases, operates early and deliberately, 
and supervises by frequent visits the after-management, has 
saved since 1880 eleven in thirteen consecutive cases of un- 



248 DIPHTHERIA; ITS NATURE AiTD TREATMENT. 

doubted membranous croup. Yet since the primary object of 
tracheotomy is simply to relieve asphyxia, and since there 
have been instances of subsequent recovery under the most 
unfavorable conditions, it would seem to be properly indicated 
in all cases in which it is probable that death by suffocation 
would take place without it. 

Another indication for the operation is often urged, namely, 
that even if it fails to save life it will secure euthanasia. The 
statements of Lovett and Munro on this point are important. 
In 232 fatal cases the proportion of deaths from the extension 
of the disease downward into the trachea and bronchi to those 
from septicaemia were as follows : 

Extension. Septicaemia. 

In all the fatal cases If to 1 

In children under 2 years 3^ to 1 

In children from 2 to 10 years 1^ to 1 

The writers remark, " It will be seen from this that young 
children are particularly liable to that distressing cause of 
death, extension of the process to the bronchi. When this 
happens there is no euthanasia; death is the slowest and most 
painful of suffocations, and only when septicaemia to the point 
of stupefaction is present at the same time does the child es- 
cape a horrible amount of suffering." 

In favor of early tracheotomy the unquestionable fact is 
urged that, in the words of Trousseau, " the earlier the opera- 
tion is performed the greater are the chances of success," and 
that the danger of the unexpectedly rapid occurrence of fatal 
asphyxia is thereby avoided. On the other hand it is argued 
that in a certain proportion of cases recovery does take place 
without operation, and that when the patient can be vigilantly 
watched and the operator can be promptly summoned in case 
of need, medical treatment should first be tried, and the opera- 
tion performed only when asphyxia is imminent. This ques- 
tion must be deckled in each particular case by a due oonsid- 



TREATMENT. 249 

eration of the circumstances attending- it. That an er»or in 
the direction of unnecessary earliness is a safer one than that 
of too great procrastination, has been illustrated in many mel- 
ancholy instances. Now that the alternative of intubation is 
available, many of the perplexities which formerly beset the 
physician in making- this decision are happily removed. 

Another indication for the early performance of tracheo- 
tomy has lately been sug-g-ested which will, in my opinion, 
assume greater prominence the more our knowledg-e of the 
pathology and treatment of the disease is perfected. Mr. W. 
W. Cheyne, 1 in view of the pathological fact that "in almost 
all cases the membrane appears first in the larynx and spreads 
thence continuously down the trachea," proposes that trache- 
otomy be performed with the greatest possible antiseptic pre- 
cautions as soon as it is evident that there is a membranous 
affection of the larynx, with the object of preventing-, by suita- 
ble disinfectant treatment applied throug-h the tracheal open- 
ing- to the mucous membrane of the larynx and trachea, the 
downward spread of the diphtheritic process. In order to 
accomplish this it is necessary that the trachea be opened 
more freely than is usual, so that throug-h the opening- the 
interior of the trachea may be inspected and antiseptic appli- 
cations may be made upward into the larynx and over the 
mucous membrane of the trachea. The details of one case are 
given, in which by removing- the advancing- membrane in the 
trachea by dissecting forceps and sponging the surface with a 
1 in 500 solution of bichloride of mercury, its progress was 
arrested. 

A different application of the same principle is reported by 
Roser. 2 At the Marburg surgical clinic the cannula used in 
tracheotomy has been surrounded with an antiseptic tampon 
prepared in the following manner : The cannula is wound with 
a muslin bandage which has first been moistened with a solu- 

1 British Medical Journal, March 5, 1887, p. 505. 

2 Revue Mens, des Mai. de l'Enf., June, 1888. 



250 diphtheria; its nature and treatment. 

tion of sublimate. While it is still moist it is sprinkled with, 
powdered iodoform. This, when dry, forms a crust which ad- 
heres to the cannula. When the instrument thus prepared is 
inserted into the trachea, the muslin swells again and forms a 
tampon. Its calibre must be such as to exactly fill the trachea. 
Thus is constituted an antiseptic barrier which the advancing 
diphtheritic process cannot pass. It is left in the trachea two 
days, and is then replaced by a fresh one, which is left until the 
fifth day. Of forty-seven tracheotomized diphtheritic patients 
thus treated during* the past three years there have been fifty- 
three per cent, of recoveries. 

The Operation. 

The high operation, in which the opening is made into the 
upper portion of the trachea, is now generally preferred as the 
easier, safer and more expeditious one. 

The patient, wrapped in a blanket, should be laid on his 
back on a table so placed that his left side shall be toward the 
window or artificial light, and his neck should be extended by 
having placed under it an ordinary wine-bottle wrapped in a 
napkin. 

Then chloroform should be given, unless the patient is 
already asphyxiated or narcotized by septic-poisoning. 

The operator should stand to the right of the patient. 

An incision through the skin should be made downward 
from the cricoid cartilage exactly in the median line for one 
and one-half inches, or more, if necessary. 

The tissues should then, under ordinary circumstances, be 
carefully and deliberately dissected down to the trachea, the 
edges of the wound being separated by retractors, and vessels 
being avoided and put aside. 

If the isthmus of the thyroid body is unusually high, it may 
be displaced downward, the muscular and ligamentous bands 
by which it is attached to the hyoid bone and thyroid carti- 
lage above having first been divided with curved scissors on 



TREATMENT. 



251 



either side of the incision opposite the first ring- of the trachea. 1 
" But in the immense majority of cases," says Sanne, " this por- 
tion of the gland is only a thin strip which passes unnoticed." 



Fig. 21.— Pilcher's Retractor. 



All bleeding- should be arrested by the forceps, clamps or 
ligature before the trachea is opened. Then the point of the 
knife should be carried into the trachea, and the two or three 
upper rings divided. 




Fig. 22.— Double Trachea Tube. Movable Plate. Silver. 

The opening of the trachea is announced by the escape of 
air. Fragments of false membrane sometimes present them- 
selves at the opening and are coughed out, or may be extracted 
by forceps. It is often advisable, before introducing the can- 




Fig. 23.— Trousseau's Dilator. 



nula, to excite coughing by inserting a feather downward into 
the trachea, that blood, mucus or fragments of false mem- 
brane may be expelled. 

1 Dr. J. A. Wyeth : "A Text Book on Surgery," p. 453. 



252 DIPHTHERIA; ITS NATURE AND TREATMENT. 

The cannula may be introduced by using the nail of the 
left index-finger as a guide into the tracheal incision, or by 
the aid of the dilator. Difficulties in doing this should be 
overcome by repeated gentle efforts, but never by force. 

A rapid operation is practiced and described by Sarnie, 1 
and advocated by Renault. 2 The trachea is grasped by its 
sides at the level of the thyroid cartilage, between the thumb 
and middle fingers of the left hand, while the index-finger of 
that hand finds the cricoid cartilage, the finger-nail being 
placed upon its lower border. This hand must not be removed 
until the cannula has been inserted. 

The incision having been made through the skin downward 
from the point indicated by the finger-nail, a few additional 
strokes of the knife bring one to the trachea. The bleeding is 
not usually of any importance in this situation. The trachea, 
being felt by the left index-finger, is punctured and incised. 
Then the cannula is taken in the right hand, and, guided by 
the left index-finger, which remains in the wound, is inserted 
into the tracheal opening. 

In this operation the prompt insertion of the cannula is 
relied upon to arrest the haemorrhage; but this promptness 
requires that the operator be expert in tracheotomy. Except 
when the rapid completion of the operation is especially called 
for, the more deliberate method should be preferred. 

To prevent infection of the wound it should be sponged 
with an antiseptic solution before the trachea is incised, and 
at the completion of the operation should be dusted with iodo- 
form and dressed with two thicknesses of linen, which should 
be moistened every hour with a solution of the bichloride of 
mercury (one in two thousand). 

In the after-treatment it is very important that the air of 
the room be kept at a proper and uniform degree of warmth 
and moisture. The diffusion through it of unirritating anti- 

^p. cit.,p. 522. 

2 "Manuel cLe Tracheotomie," by Dr. P. Renault; Gr. Steinheil, 6"diteur. 



TKEATMEKT. 253 

septic vapors, such as have already been referred to (page 197), 
is a valuable addition. 

The tube must be vigilantly and intelligently watched. 
Whenever it becomes obstructed by the discharges or frag- 
ments of false membrane, the inner tube must be withdrawn 
and cleansed. 

The use of mild antiseptic atomized solutions administered 
with the inspired air through the tube may be practiced. 
The spray of carbolic acid and lime-water (page 215) is es- 
pecially appropriate. Mild solutions of borax or boracic acid 
may be similarly used, or insufflations of iodoform, as referred 
to on page 186. 

If there is false membrane below the tube, the frequent in- 



G. TIEMANN. & CO. 




Fig. 24.— Trousseau's Tracheal Forceps 



troduction of solutions of trypsin or papayotin in spray, or by 
means of a slender quill, may be resorted to. 

The dislodgment and removal of obstructing membrane 
below the tube has in some cases been effected by means of 
forceps or the croup-brush, or an instrument which is made by 
surrounding the end of a soft flexible urethral catheter with a 
ring five or six millimetres in diameter. 1 

After the expiration of twent3 7 -four hours from the opera- 
tion, and at such subsequent intervals as are requisite, the 
cannula should be removed to facilitate the ejection of ac- 
cumulated matter from the trachea and the inspection and 
dressing of the wound. 

When air begins to pass through the larynx, the cannula 
may be removed for a short time, which may be repeated and 
the time extended as the patient becomes more able to dis- 

1 Roser, Loc. cit. 



254 DIPHTHERIA; ITS NATURE AND TREATMENT. 

pense with it, until it is finally removed altogether. The length 
of time from the first insertion to the final removal of the 
cannula varies very greatly in different cases. In a large 
majority of all cases this period does not exceed eight days, 
hut in some instances it is several months or even years. 

The Treatment of Diphtheritic Paralysis. 

Since diphtheritic paralysis is due to the immediate or 
remote effect upon the nervous system of the diphtheritic 
poison, and since it usually disappears pari passu with the 
accompanying anaemia, the measures especially indicated in 
its treatment are those which tend to counteract the former 
and remove the latter. These are rest, fresh air and a restora- 
tive regimen. Among drugs the tincture of the chloride of 
iron, the actions of which as a haemic restorative, a stimulant 
tonic, and an eminently efficient antidote to the debilitating 
poison of diphtheria have been elsewhere referred to, is in- 
comparably the most useful. My own experience in the treat- 
ment of quite a large number of cases has furnished a striking 
illustration of this fact. The medicinal treatment of these 
cases has invariably consisted mainly in the continued fre- 
quent administration of iron by one of the formulae given on 
page 220. The rapidity with which the paralysis has disap- 
peared, even in some grave cases, has been remarkable. 

The tendency of the affection, in the great majority of cases, 
to early recovery, and, even in the more severe and persistent 
ones, to an ultimate restoration of function, which is often 
rapid when it has once commenced, would naturally lead to 
the attributing of special curative virtues to whatever drug 
or method of treatment might chance to have been employed. 
Hence strychnine and electricity have received a large meed 
of credit for many recoveries. 

With regard to the beneficial effect of electricity experience 
and opinions differ. Dr. A. D. Rockwell, of this city, informs 
me that according to his experience in a considerable number 



TREATMENT. 255 

of cases it has seemed to shorten the duration of the affection. 
Seeligmiiiler x attaches much importance to its use. The con- 
stant current should be employed. When the velum palati is 
affected the positive pole should be placed on the nucha, the 
negative one under the inferior maxilla; in ocular paralysis, 
the positive pole on the nucha, and the neg-ative in the vicinity 
of the paralyzed muscles; in paralysis of the lower extremities, 
the positive over the lumbar region and the neg-ative over the 
nerves which are to be excited. Gowers 2 recommends the use, 
in severe cases, of the voltaic current, slowly interrupted, in 
such streng-th, if possible, as will cause the affected muscles to 
contract; but in the case of children the use of a weaker cur- 
rent is far preferable to the exciting of distress and alarm by 
a strong-er one, " since the utmost g-ood that electricity can do 
is very small compared with the harmful influence of a daily 
fright." Gentle friction or massag-e over the affected region 
often seems to be beneficial, but any violent or fatig-uing- pro- 
cedures of the kind are strongly contra-indicated. 

Strychnine in small doses may doubtless render valuable 
service in aiding to restore the tone and activity of the diges- 
tive organs. Gowers 3 says that while it sometimes seems to 
be of service " it is certainly powerless to neutralize the mor- 
bid process in its early stages, and seems to be without influ- 
ence on the spread of the disease. Moreover it is not wise to 
give large doses of a drug that stimulates the nerve-cells so 
powerfully." In cases of extreme paralysis of the muscles of 
deglutition and respiration, its hypodermic use has seemed to 
be beneficial. Reinard, 4 reports a favorable result of the daily 
injection of one milligramme (-g^ grain) of sulphate of strych- 
nia in a desperate case of general diphtheritic paralysis in- 
volving the muscles of respiration. After the first injection 
respiration was easier, and a cure was effected in fifteen days. 

1 E. Adler : Med. Chirurg. Rundschau, No. 4, 1886. 

2 Diseases of the Nervous System, p. 1236. 
3 Loc. cit. 

4 Deutsche Med. Wochenschrift, 1885, No. 9. 



256 diphtheria; its nature and treatment. 

Dr. W. H. Thomson 1 has found the recourse to strych- 
nia and electricity very disappointing-; but he states that 
topical irritants seem occasionally to be quite effective. In 
palatine and pharyngeal paralysis he brushes the parts 
every few hours with a paste of black pepper and honey, with 
a view to awakening- their lost reflex excitability. In paraly- 
sis of the limbs, trunk, etc., he has the parts enveloped twice 
a day in a pack of infusion of capsicum of the streng-th of a 
drachm of the powder to a pint of boiling- water, the applica- 
tion to last from ten to twenty minutes. 

The difficulty of deglutition is, in some cases, one of the most 
serious complications to overcome. When the paralysis is in 
the palate, solid or semi-solid food can be swallowed ; but when 
the muscles of the pharynx and upper part of the larynx are 
affected, with insensibility of the epiglottis, the administering 
of food by the ordinary means becomes dangerous or impossi- 
ble from its tendency to enter the larynx. In such cases resort 
must be had to the oesophageal tube or a large catheter or to 
rectal enemas. The necessity of giving nourishment by one 
or both of these methods is imperative in order to avoid the 
danger of exhaustion. 

In the case of serious dyspnoea and danger of suffocation 
from the accumulation of mucus in the bronchial tubes in 
paralysis of the respiratory muscles, resort to artificial respira- 
tion may tide the patient over a dangerous emergency. Dr. 
W. H. Thomson suggests that in such cases the treatment 
which is so successful in cases of bronchial palsy be tried. 
" The patient should be let down on his hands from the bed 
with his head down, and encouraged to cough, and frequently 
a short recourse to this measure will result in expelling a 
quantity of suffocative fluids from the trachea with great relief 
to the respiration for some time." In such cases the applica- 
tion of the faradic current to the skin of the back of the chest 

1 Medical News, June 4, 1888, p. 635. 



TREATMENT. 257 

with a view to the reflex stimulation of the respiratory centre 
has been found promptly serviceable by Duchenne. 1 

For the sudden heart-failure which sometimes occurs in the 
first or second week of diphtheria, all remedies are too often 
unavailing-. The patient must be kept strictly quiet in the 
recumbent position. A hot poultice, over which mustard has 
been dusted, should be applied over the cardiac region. Warm 
stimulating* applications and rubbing" should be kept up over 
the extremities. Brandy or whiskey should at once be given 
hypodermically, and small doses of digitalis may be given in 
the same manner. Faradization over the cardiac region is 
recommended by Duchenne as a powerful cardiac stimulant 
under such circumstances. Ammonia, camphor, musk, and 
other stimulants are recommended, but are of doubtful utility, 
especially as the tolerance of the stomach for drugs and food 
is usually very limited, and should be carefully economized. I 
have seen small doses of coffee and of beef-juice, and cham- 
pagne given pretty freely, well retained and beneficial. By 
the judicious use of the measures referred to, the patient may 
sometimes be carried through an alarming emergency, though 
too often their good effect is only transient. 

The milder forms of cardiac paralysis, which usually appear 
at a later period in connection with other forms of diphtheritic 
palsy, may be treated by the remedies which have been already 
referred to as appropriate for that condition, with the addition 
of small doses of digitalis; and the special danger of any vio- 
lent exertion or even of suddenly rising from the recumbent 
position should always be borne in mind. 

Diphtheritic Conjunctivitis. 

In the treatment of diphtheritic conjunctivitis, the follow- 
ing measures are indicated : 

In the first stage, small pieces of lint, cooled on a block of 
ice, should be laid over the eye and changed every minute or 

*" Selections from the Works of Duchenne," by Dr. Poore, p. 35G. 

17 



258 DIPHTHERIA; ITS NATURE AND TREATMENT. 

two ; in the second stage warm or moderately cold applica- 
tions should be used according- to the sensations of the patient. 

Antiseptic solutions, such as mercuric bichloride (1 in 8000). 
carbolic acid (30 minims to the pint), or boric acid (one to four 
drachms to the pint) should be dropped into the eye hourly. 
The most thorough cleanliness must also be maintained by 
irrigation with the same or weaker solutions, used warm or 
tepid. Dusting iodoform into the eye has been recommended. 

In the third stage astringent solutions, as of nitrate of 
silver (5 — 10 grains to the ounce), or tannin (20 grains to the 
ounce) applied once or twice a day are useful. 

In case of great pressure upon the cornea from the swell- 
ing of the eyelid, canthoplasty should be performed. 

The greatest care must be taken to prevent the infection 
of the sound eye, by protecting it with an impermeable cover- 
ing. 

Cutaneous Diphtheria. 

The ordinary forms of cutaneous diphtheria usually recover 
rapidly when simply kept clean, dusted over with iodoform, 
and covered with lint, which is kept moistened with a mild 
antiseptic solution, as of bichloride or carbolic acid. 

The more serious forms of wound-diphtheria, which some- 
times occur in hospitals, should be treated on the same princi- 
ples as hospital gangrene. The false membrane and necrosed 
tissues should first be destroyed or removed. This may be 
done by means of the galvano-cautery ; or they may be dis- 
sected away as completely as possible, after which bromine is 
applied, and then the wound is covered with iodoform, and 
dressed antiseptically. 



APPENDIX. 



A recent contribution to the etiology of diphtheria * by 
MM. Roux and Yersin of the Pasteur Institute, Paris, has 
reached me too late for its statements to be incorporated into 
the chapter on that subject; but those statements are, prima 
facie, so important in view of the corroboration which they 
furnish to previous observations which have been referred to 
in that chapter, that a summary of them is here appended. 

MM. Roux and Yersin have found the bacillus of Klebs and 
Loeffler (described on page 37) in the false membranes in every 
one. of fifteen cases of human diphtheria examined by them. 
They have isolated it in pure cultures by methods nearly iden- 
tical with those of Loeffler. They state that it is freely repro- 
duced in the absence of air, but less energetically than in its 
presence. It maintains its vitality for a long- time in nutritive 
media, having* been thus preserved for more than six months 
in tubes hermetically sealed. 

The cultures made by the authors have been more active 
than were those of Loeffler, the effect of their inoculation into 
animals having" been more uniform and more fatal, but in most 
other respects the results of their experiments have been iden- 
tical with those described by him. 

In inoculations of the culture upon mucous membranes they 
have found it necessary to first excoriate them; merely smear- 
ing- it over healthy mucous membranes produces no result. 

1 "Contribution a FEtude de la Diphtherie, par E. Roux et A. Yer- 
sin," Annales de f Institut Pasteur, Decembre, 1888. 



260 diphtheria; its nature and treatment. 

The affection produced by inoculations in the trachea of the 
rabbit strikingly recalls the features of human croup — conges- 
tion of the mucous membrane, false membrane, oedematous 
swelling- of the tissues and the glands of the neck, dyspnoea, 
stridulous breathing, asphyxia. 

Injections of the culture beneath the skin of pigeons, rab- 
bits and guinea-pigs, in sufficient quantity, caused their death 
in from thirty-six hours to five days, the period varying accord- 
ing to the susceptibility of the animal and the amount of the 
culture introduced. In the rabbit the autopsy showed at the 
point of inoculation an extensive oedema infiltrating a tissue 
indurated with hemorrhagic points, swelling of glands, con- 
gestion of the omentum and mesentery, with small ecchymoses 
along the vessels; the liver friable, of a yellow tint, and the 
seat of a grayish degeneration. In guinea-pigs, which are the 
most susceptible to the action of the bacillus of diphtheria, the 
post-mortem lesions consisted in a grayish membranous coat- 
ing at the point of inoculation, a gelatinous oedema of greater 
or less extent, a general dilatation of blood-vessels, congestion 
of glands and internal organs, especially of the suprarenal 
capsules, the pleurae being often filled with a serous effusion 
and the pulmonary tissue sometimes in a state of splenization. 

After intravenous injections in rabbits of one cubic centi- 
metre of the culture, the animals usually died within sixty 
hours. The lesions found at the autopsy were a general con- 
gestion of the abdominal organs, dilatation of vessels, swelling 
of glands, acute nephritis, and the hepatic degeneration already 
referred to. 

Is the bacillus from a very infectious case of human diph- 
theria more active than those from a benign case ? Without 
being able to definitively answer that question, the authors 
state that a culture from the false membrane of a very benign 
case w r as found to be very active when inoculated into rabbits. 

From the results of a large number of careful examinations 
the authors confirm the observations of Loefner and others 



APPENDIX. 261 

that the bacillus of diphtheria is to be found only in the false 
membranes and at the point of inoculation, and never in the 
blood or the organs, except transiently and accidentally (as, 
for instance, within a few hours after intravenous injections) 
and it is never reproduced there. In rabbits, after intravenous 
injection, the microbes had entirely disappeared within sixteen 
hours ; yet the malady pursued its course, and the rabbits died 
in from thirty to thirty-six hours. 

Diphtheritic Paralysis. — MM. Eoux and Yersin have been 
the first to succeed in experimentally producing- diphtheritic 
paralysis in animals. They have produced this result by in- 
tratracheal, subcutaneous or intravenous inoculations in nu- 
merous instances in which the animal did not succumb to a too 
rapid intoxication. Paralysis commenced in a pigeon three 
weeks after inoculation in the pharynx, when the false mem- 
branes had disappeared and the animal seemed to have com- 
pletely recovered. The powerlessness of the feet and the wings 
was almost complete. When this muscular feebleness had 
continued for a week there was an amelioration in the move- 
ments of the feet, but the rabbit died five weeks after the in- 
oculation. The autopsy showed no lesion, either of the articu- 
lations or of the nervous system, to account for the symptoms. 
Many of the localizations which occur in human diphtheritic 
paralysis were observed in various cases. In rabbits the first 
invasion of the paralysis was usually by the posterior extrem- 
ities, and it progressed so rapidly that in a day or two it 
affected the whole body, and the animal died by failure of the 
respiration or of the heart's action. In rarer instances the 
paralysis in rabbits began in the muscles of the neck, the rab- 
bit being unable to raise the head from the ground, or in the 
lar3mx, causing hoarseness of the voice. The authors remark : 
" The occurrence of these paralyses, following the introduction 
of the microbe of Klebs and Loeffler, completes the resemblance 
of the experimental disease to the natural malady, and estab- 
lishes with certainty the specific role of that bacillus." 



262 diphtheria; its nature and treatment. 

The Diphtheritic Poison. — The truth of the conclusion 
which has been reached by Loeffler and others that the bacillus 
exerts its morbific effect by means of an active poison which 
is produced by the microbe at the seat of the local affection 
and thence diffused through the system, has also been demon- 
strated by the experiments of MM. Roux and Yersin. They 
have done this, not by isolating" the poison, but by pursuing 
the following method: Filtering through porcelain a pure 
culture of the bacillus in bouillon of veal, which is seven days' 
old, all the microbes are retained by the filter, and the liquid 
obtained is perfectly limpid and slightly acid. If this liquid 
is introduced in doses of from two to four cubic centimetres 
beneath the skin of animals, it does not make them ill. If, 
however, a dose of 35 c.c. is injected into the peritoneal cavity 
of a guinea-pig or the veins of a rabbit, the animal for a time 
appears to be well, but after two or three days becomes inquiet 
and trembles, is increasingly feeble, is seized with a profuse 
diarrhoea, the respiration becomes labored and irregular, he 
is no longer able to move, and dies without convulsions five 
or six hours after the commencement of the symptoms. A 
guinea-pig which has received 35 c.c. of the same liquid into 
the peritoneum dies after about ten hours, having experienced 
great difficulty in respiration. The autopsy shows the char- 
acteristic congestion of the viscera, especially the kidneys and 
the suprarenal capsules, and there is often a pleuritic effusion. 
If quantities of the filtered liquid, varying from \ c.c. to 2 c.c, 
are introduced under the skin of guinea-pigs, they are presently 
seized with the same symptoms, and die in the same manner, 
as those which have been inoculated with the living culture, 
after periods varying from twenty -four hours to three days, 
according to the dose administered. The lesions are also the 
same, except that false membrane is wanting. There is the 
same oedema, the same indurated tissue at the point of inocu- 
lation, the same hemorrhagic congestion of the organs, espe- 
cially of the kidneys and the suprarenal capsules, and the same 



APPENDIX. 263 

pleuritic effusion. In short, "the malady — both symptoms 
and lesions — is communicated as certainly by the injection of 
the filtered poison as by the inoculation of the bacillus." 

The symptoms produced by the inoculations of the filtered 
fluid, vary according" to the dose of the poison contained in the 
culture. In the case of a guinea-pig* dyspnoea began on the 
fifth day, and continued for a week; the respiration was dia- 
phragmatic and jerking. When the animal was obliged to 
run, the oppression became so great that he fell, almost as- 
phyxiated. These symptoms amended gradually, and he re- 
covered. In rabbits the same commencement of the paralysis 
in the posterior extremities and its rapidly fatal generaliza- 
tion, which has been already described, occurred. When the 
intoxication is less severe, the paralysis may remain for some 
time limited to a group of muscles. 

Animals which, like rats and mice, are not affected by the 
inoculation of the bacilli, show the same resistance to the fil- 
tered poison. 

Is the diphtheritic poison an alkaloid or a diastase ? While 
not yet prepared to definitively answer that question, the au- 
thors state that the activity of the toxic matter is greatly 
diminished by heat, and also by exposure to the air — circum- 
stances which favor the latter hypothesis. 

The first part of a study of the etiology of diphtheria 1 by Dr. 
T. M. Prudden, which is very important both from the com- 
pleteness and precision of its methods of investigation and the 
definibeness of its results, appears just as this work is going- 
to press. It consists of bacterial examinations, morphological 
and by cultures, in twenty-four fatal cases of diphtheria. In 
most of the morphological examinations micrococci, usually 
in large numbers, were found in all parts of the false mem- 
branes, including their deeper layers, in the necrosed epithe- 
lium, in some instances in the lymph-spaces of the mucosa and 

1 " On the Etiology of Diphtheria," by T. Mitchell Prudden, M.D., 
American Journal of the Medical Sciences, April, 1889. 



264: diphtheria; its nature and treatment. 

submucosa, and in one instance extending* deeply into the sub- 
mucous tissues, accompanied, when abundant, with necrosis. 
The cocci in the false membrane were accompanied by other 
bacteria, among* which in some of the cases, are mentioned 
various forms of bacilli; but these are usually described as few, 
scattering", and limited to the more superficial portions of the 
false membranes. In two exceptional cases micrococci were 
wanting*, and bacilli were numerous. 

In most of the cultures from the false membranes strepto- 
cocci, usually in great numbers, and, in some instances, in 
nearly pure cultures, appeared. The other bacteria, including* 
the various forms of bacilli, were not uniformly present and 
were, in most cases, in much smaller numbers. In the two ex- 
ceptional instances already referred to (in which the larynx 
and trachea were lined with dense firm false membrane, but 
there was no false membrane in the pharynx) no colonies of 
streptococci appeared in the cultures, bat " short, stout, round- 
end bacilli " were numerous. In seven cases, cultures of strep- 
tococci, in most instances pure, were developed from one or 
more of the internal org*ans, namely the kidneys, the spleen, 
the lung's and the liver. 

These observations, as is remarked by the author, seem to 
point to the importance of the streptococcus. A stud}^ by him 
of its characters and life-history will be subsequently published. 



INTUBATION IN CROUP 



AND OTHER 



ACUTE A~KD CHRONIC FORMS OF STE 

ISTOSIS OF THE LAETSX. 




^Juyek e W**' 



The earliest record of catheterization of the larynx is found 
in the writings of Hippocrates, who suggested that in cases of 
inflammatory cynanche, cannulas should be carried into the 
throat along the jaws so that air might be drawn into the 
lungs. 

This suggestion was adopted by many of the ancient phy- 
sicians until the discovery of bronchotomy (tracheotomy) by 
Asclebiades about a century before ths Christian era. Cathe- 
terization was then lost sight of until 1780, when it was revived 
by Chaussier, who proposed the use of a laryngeal tube in the 
asphyxia of the new-born and to overcome obstruction due to 
disease. 

Several attempts were made about this time to retain a 
catheter in the larynx but were unsuccessful owing to the 
sensibility of the parts. 

Dissault in 1 801, and many others after his time, appear to 
have had some measure of success in the treatment of laryn- 
geal stenosis by this method, particularly in adults. But the 



266 INTUBATION IN CROUP AND OTHER 

retention of one end of a tube in the trachea, while the other 
protrudes either from the mouth or nose, is obviously imprac- 
ticable in children. 

The first and only attempt before my own to use a short 
tube in the larynx, that would allow the epiglottis to close over 
it, was made by Bouchut in 1858. His failure after a limited 
trial was due principally to his extravagant claims for the 
new operation as a substitute for opening- the trachea before 
he had any results to show, and to his bitter denunciation of 
Trousseau's pet operation, tracheotomy, which Bouchut 
claimed had considerably increased the death rate from croup 
instead of diminishing it. Personal enmities therefore played 
a more important part than the merits or demerits of the 
new procedure in determining the final decision of the Acad- 
emy against it. 

A very complete bibliography of this subject under the 
titles of catheterization of the larynx, tubage of the glottis, 
and intubation will be found in a paper by Dr. Dillon Brown 
in the Transactions of the 9th International Medical Congress, 
section on Diseases of Children. 



DESCRIPTION OF INTUBATION INSTRUMENTS. 

A set of instruments for children, under the age of puberty, 
consists of six tubes (1) of different sizes and varying in length 
from one and a half to two and a half inches; an introducer, 
(fig. 2), an extractor, (fig. 3), a mouth gag (fig. 4), and scale 
of years (fig. 5). Each tube is provided with a separate ob- 
turator for the purpose of attaching it to the introducer and, 
by projecting somewhat beyond the distal extremity, produces 
a probe-point which prevents injury to the tissues on the de- 
tachment of pseudo-membrane during the operation. The 
numbers on the scale (fig. 5) represent years, and indicate ap- 
proximately the ages for which the corresponding tubes are 
suitable. 



FOKMS OF STENOSIS OF THE LARYNX. 



267 





Fig. 1. 



Fig. 2. 




Fig. 3 




Fig. 4. 



Fig. 5. 



268 INTUBATION" IN CROUP AND OTHER 

The smallest tube when applied to the scale will reach the 
line marked 1, and is suitable for children of one year and 
under. In children of fifteen months, small for age, this size is 
preferable to the two-year size, and it can be used at eighteen 
months, or even two years, without the slightest danger of 
passing through, but is apt to be coughed out. The next size, 
which reaches the line on the scale marked 2, is intended for 
children between one and two years, but can also be used at 
two and a half or three years with objection referred to ?bove. 
The third size, marked 3-4 on the scale, should be used in cases 
over two and up to four years, and so on. The female larynx 
in children as well as in adults is smaller than the male, which 
should also be considered in selecting the proper tube to be 
used. 

Owing to the rapid increase in the size of the larynx at the 
age of puberty, the string should be left attached to the largest 
tube when used after this period of life. 

In measuring the tubes to select the proper size, the heads 
are of course included. 

The tube indicated by the scale of years, is never too large 
to pass through any form of acute stenosis, except in rare 
cases of extreme subglottic infiltration of the mucous mem- 
brane, in which a smaller size may have to be used. Fig. 6 
shows a specimen of this kind, with cross section through cri- 
coid cartilage less than a quarter of an inch below the vocal 
cords. To pass the proper sized tube through a stricture of 
this nature, surrounded as it is by an unyielding cartilaginous 
ring, requires more or less force, and these are the only cases 
in which it is justifiable. 

Fig. 7 represents the normal lumen of the subglottic 
division of the larynx from a child of the same age, and Fig. 
8 a section from the trachea of the same showing the great 
difference in the caliber of the air passage at these points. 

I have used the 5-7 tube at two years of age either to ob- 
tain the benefit of the increased length or larger head, and 



FORMS OF STENOSIS OF THE LARYNX. 



269 



this can be adopted where there is pseudo-membrane produc- 
ing- obstruction at the lower extremity or swollen tissue over- 
lapping* the head of the smaller tube. Greater interference 
with deglutition and the danger of ulceration if the tube be 
long retained, are the only objections to this plan. All such 
indications could be met by a greater variety of tubes. 

When the proper tube for the case to be operated on has 
been selected, a strong thread of silk or linen is passed through 
the small eyelet intended for this purpose, and the ends tied 
together. Braided silk is the best, as it will not unravel if one 





Fig. 6. 



Fig. 7. 



Fig. 8. 



strand should cut and thus block the opening, which sometimes 
happens with the twisted variety. Leaving this string too 
short has been the cause of much annoyance to several opera- 
tors and alarm to the friends of the patient by allowing* the 
tube, when placed in the oesophagus, to slip into the stomach, 
which it quickly does if the malposition be not recognized. 
This accident can always be avoided by leaving the thread 
long enough to reach the stomach and still leave a portion 
protruding from the mouth. The obturator is then screwed 
firmly on the introducer to prevent the tube from rotatiug 
while being inserted, which would be liable to bring the pos- 
terior projecting portion of the flange under the epiglottis. 



270 INTUBATION IN CKOUP AND OTHER 

The upper end of the tube is curved backward and the shoulder 
removed anteriorly to allow greater freedom to the epiglottis 
during the act of swallowing. 

The long diameter of the tube when applied and ready for 
use, should be in a line with the handle of the introducing in- 
strument. If found to turn too far, as usually happens after 
considerable use, a washer of writing paper, of one or more 
thicknesses, is sufficient to hold the obturator in the proper 
position. If the lower extremity of the obturator does not 
project far enough beyond the tube to make a smooth blunt 
point, it will be found that the thread is too thick or is not in 
the groove corresponding to the hole in the tube. In most of 
the instruments made at present, the eyelet is in the left an- 
terior part of the shoulder, which removes this difficulty. 

Indications for Intubation. — The indications for intuba- 
tion are the same as for tracheotomy. There is no reason 
why one should be performed earlier than the other. The •be- 
ginning of the third or suffocative stage is the proper time to 
interfere. This is marked by more or less sinking in of the 
yielding portions of the chest, lower ribs and sternum, episternal 
notch, and supra-clavicular regions with inspiration. It means 
simply that air cannot gain admission to the lungs in sufficient 
quantity to fill the partial vacuum created by the expansion 
of the chest, and the walls recede under the weight of the at- 
mosphere. It is more marked in very young or rachitic chil- 
dren owing to the greater elasticity of the ribs. But it should 
be remembered that this symptom is not peculiar to stenosis 
of the larynx and trachea, as it is produced to a lesser degree 
by obstruction in any part of the respiratory tract that inter- 
feres with the free inflation of the lungs. It is found in capil- 
lary bronchitis, extensive deposits of pseudo-membrane in the 
bronchi, atelectasis, and to some extent even in broncho-pneu- 
monia. Recessions at the root of the neck are more significant 
than those below, as the violent contractions of the diaphragm 
aid in drawing- in the free border of the ribs and sternum. 



FORMS OF STENOSIS OF THE LARYNX. 271 

When recessions are marked there is little or no respira- 
tory murmur over the posterior portion of the chest, but this 
symptom is not always available owing- to the laryngeal 
stridor. 

Atelectasis with excessive quantity of blood in the lungs, 
as would naturally be expected, is the result of death from ob- 
struction in the larynx, but there are exceptions to this rule, 
and these organs are occasionally found distended with air 
and containing less than the normal amount of blood. This 
acute general emphysema, which produces bulging of the 
parts that usually recede, is caused by greater impediment to 
expiration than inspiration, and air accumulates in the lungs 
in the same manner as in spasmodic asthma. It is not com- 
mon in croup, but is worth remembering. It is also occasion- 
ally found in capillary bronchitis. 

The downward movement of the larynx with inspiration is 
pathognomonic of serious obstruction in this organ, and is also 
the result of atmospheric pressure, the air being prevented 
from entering with sufficient rapidity to fill the partial vacuum 
below. It is readily detected in adults, but not so in children, 
owing to the deeper situation of the larynx in the latter. 

This symptom is not present in stenosis of the trachea, 
owing to the great elasticity of this tube, which permits of 
considerable motion on itself without displacing the larynx, 

Abiding cyanosis is too late a symptom to wait for, and, 
besides, it is uncertain, as fatal obstruction may exist in the 
glottis with extreme pallor of the surface. This pallor of 
asphyxia is produced by the excessive quantity of blood drawn 
into and stored in the lungs by the cupping-glass action of in- 
spiration when the air is almost excluded. The blood in the 
cutaneous capillaries is thus reduced to a minimum, and this, 
although highly charged with carbonic acid, only serves to 
increase the paleness, on the principle that the addition of a 
little blue makes a clearer white. 

The temporary cyanosis which comes and goes with the 



272 INTUBATION IN CROUP AND OTHER 

paroxysmal dyspnoea of the second stage of croup is of no 
particular significance. 

Children seldom remain long in one position when suffering 
severely from want of breath, and continued restlessness, if 
consciousness be unimpaired, is therefore an important indica- 
tion that it is time to afford relief. 

As far as the necessity for intubation is concerned, it mat- 
ters little as to the nature of the obstruction provided it be in 
the larynx and not a foreign body. It may be croup, simple 
laryngitis, oedema of the glottis, paralysis, spasm, or even a 
neoplasm. In the latter it will tide over the immediate danger 
of asphyxia, and leave more breathing room to facilitate the 
radical operation. 

Method of Operating. — The nurse or person who holds the 
child should be seated on a solid chair with low back, and the 
patient placed on the lap with head resting on left shoulder of 
nurse in order to leave the gag free. The hands can either 
be held, or, still better, secured by the sides by a towel or sheet 
passed around the body and left in that position until the tube 
is inserted and the string removed. Fastening the hands in 
front of the chest or thick garments in the same location rea- 
ders it more difficult to depress the handle of the introducer 
sufficiently to carry the tube over the dorsum of the tongue. 

The gag (fig. 4) is then inserted well back behind or be- 
tween the teeth in the left angle of the mouth and opened 
widely, care being taken not to do it too suddenly or to use 
too much force. In children who have not at least one bi- 
cuspid on the left side, the gag should not be used, as it slips 
forward on the gums, and, besides being in the way, is liable to 
injure the incisor teeth. There is little difficulty in these cases 
in keeping the mouth sufficiently open with the finger, if car- 
ried far enough to the patient's right to be out of range of the 
front teeth. Allowing the child to compress the finger be- 
tween the gums for a few seconds until the jaws relax, before 
carrying it into the fauces, avoids the necessity for using force. 



FORMS OF STENOSIS OF THE LARYNX. 



273 



The Denhardt gag-, which is the one shown in the cut, holds 
better than the one originally devised by the author, the 
handle of which projects downward and is liable to be knocked 




Fig. 9, shows the positions of assistant, nurse and patient with gag in position. 

out of place by coming in contact with the shoulder in the 

movements of the child's head. 

An assistant stands behind the patient and holds the head 

firmly by placing one hand on either side, and at the same 

time slightly elevates the chin. The person who holds the 
18 



274 INTUBATION IN CROUP AND OTHER 

head, if without any experience, should be requested not to 
touch the gag, as this, if properly placed, retains its hold by 
the pressure of the teeth. 

The operator stands in front of the patient holding" the 
introducer lightly between the thumb and fingers of the right 
hand, the thumb resting on the upper surface of the handle 
just behind the knob that serves to detach the tube and the 
index finger in front of the trigger support underneath. 

Held in this manner it is impossible to use force enough to 
make a false passage, while if firmly grasped in the hand the 
beginner may, unconsciously, exert sufficient force to lacerate 
the tissues. 

The index finger of the left hand is carried well down in 
the pharynx or beginning of oesophagus and then brought 
forward in the median line, raising and fixing the epiglottis, 
while the tube is guided along beside it into the larynx. If 
any difficulty is experienced in locating the epiglottis, it is 
better to search for the cavity of the larynx, a cul de sac into 
which the tip of the finger readily enters and which cannot be 
mistaken for anything else. Once in this cavity the epiglottis 
must be in front of the finger and the latter is then raised and 
pressed towards the patient's right to leave room for the tube 
to pass beside it. The distal extremity of the tube should be 
kept in contact with the finger, and even directing it a little 
obliquely towards the right side of the larynx is necessary to 
get inside the left ary-epiglottic fold, especially in very young 
children. 

The handle of the introducer is held close to the patient's 
chest in the beginning of the operation, and rapidly raised as 
soon as the lower end of the tube has passed behind the epi- 
glottis, otherwise it will slip over the larynx into the oesopha- 
gus. 

Some operators hold the introducing instrument in the 
horizontal position until the tube is well back in the fauces, 
and then swing it around to the middle line and complete the 



FOKMS OF STENOSIS OF THE LARYNX. 275 

operation in the usual manner. The beginner is liable to for- 
get the latter movement, which is the only objection to this 
plan. 

As soon as the cannula is inserted it is detached by press- 
ing forward the button on the upper surface of the handle 
with the thumb, while counter-pressure is made with the index 
finger on the trigger beneath. In removing the obturator — the 
joint in the shank of which is intended to facilitate this part 
of the operation — the movements required for insertion are 
reversed. To prevent the tube from being also withdrawn, 
the finger must be kept in contact with its shoulder either on 
the side or posteriorly. 

The tube should be carried well down in the larynx before 
detaching it, otherwise the lower aperture will be left open 
and liable to strip off pseudo-membrane as it is subsequently 
pushed home with the finger. 

The gag is removed as soon as the tube is in place, but the 
string is allowed to remain long enough to be certain that the 
dyspnoea is relieved and that no loose membrane exists in 
the lower portion of the trachea. In some cases the presence 
of the thread is desirable because it excites more cough, which 
is necessary to expel accumulated secretions and to inflate 
any collapse of the lungs that may have taken place. In re- 
moving the string the finger must be re-inserted to hold the 
tube down, but the gag is rarely necessary, as children old 
enough to understand readily open the mouth for this purpose. 

In withdrawing the tube the child is held in the same posi- 
tion, and the extractor is guided along the side of the finger, 
which is brought in contact with the head of the cannula and 
then pressed toward the patient's right in order to uncover 
the aperture and allow the instrument to enter in a straight 
line. Dr. Waxham and others pass the extractor under the 
finger, that is, between it and the epiglottis, and intubate in 
the same manner. I have not tried this method and cannot 
therefore express an opinion as to its merits. No attempt at 



276 INTUBATION IN CROUP AND OTHER 

extraction should be made until the head of the tube is felt, 
which can always be done no matter how extensive the swell- 
ing- of the epigiottis and ary-epiglottic folds may be. Many 
times the tissues have been lacerated by repeated attempts to 
remove a tube from the larynx which was somewhere else, 
most likely in the bed or ejected, unobserved, into a vessel 
during the act of vomiting, and thrown out. 

The tubal cough is characteristic, and when once heard 
cannot be mistaken, but it sometimes assumes a hoarse or 
croupy quality from loose membrane below or overlapping 
tissues above, and in such cases the presence of the tube must 
be demonstrated by the sense of touch. 

To place a tube in the larynx of a struggling, choking child, 
in the brief space of time that is compatible with safety, is a 
difficult thing to do, and should not be attempted, except in 
case of emergency, without previous practice on the cadaver. 
Those only who possess an extraordinary amount of dexterity 
combined with coolness will succeed without such practice. 
The operator has so many things to think of and so many 
movements to make with both hands, all in a few seconds, 
that unless he have had sufficient practice to make some of 
these movements to a certain extent automatic, he cannot 
operate with safety to his patient or with credit to himself. 
The epiglottis must be found, raised and held in this position, 
as the tube is glided down in contact with the finger, other- 
wise the operator does not know where it is ; it must be slipped 
off at the right moment and held down while the obturator is 
withdrawn, all to be accomplished in ten seconds or less. It 
is this important element of time, therefore, that converts an 
otherwise simple operation into a very difficult one. 

Practice on the cadaver is within the reach of compara- 
tively few, but a larynx from any of the smaller animals can 
be procured by every one; and repeated practice on this, placed 
upright in the neck of a bottle or other convenient receptacle, 
is an excellent substitute. I have always advised those to 



FORMS OF STENOSIS OF THE LARYNX. 277 

whom I have given practical instruction on this subject to 
continue this kind of practice at frequent intervals, because a 
few lessons on the cadaver are not sufficient to insure pro- 
ficiency and have only the advantage over this method of 
learning to operate in the same small space that exists in the 
living subject. 

The larynx should be placed in the same position it occu- 
pied in the body, the operator going* through the different 
steps of inserting and removing the tube solely by the sense of 
touch without watching his own movements, and when any 
obstacle is encountered holding the introducer or extractor in 
position until he investigate the cause of the difficulty. An 
hour's rehearsal of this kind just before going to remove a 
tube from a patient is of the greatest advantage, and gives an 
amount of confidence that contributes largely to a successful 
result. 

I have found the greatest difficulty in overcoming the 
habit, always adopted by beginners, of placing the thumb on 
the lever of the extractor while guiding it into the tube. The 
most expert operator cannot do this without running the risk 
of unconsciously making slight pressure too soon, thus sepa- 
rating the nibs, which are very liable to seize some of the tis- 
sues as they close, besides otherwise interfering with the 
success of the operation. The thumb should be constantly 
occupied by placing it on the upper surface of the handle until 
the instrument is introduced, then transferred to the lever and 
continuous pressure kept up while the tube is being removed. 
Intermittent pressure will allow the tube to drop off into the 
pharynx and possibly to enter the stomach. 

Intubation performed by an expert is an operation that 
may be witnessed by the most sympathetic mother without 
material shock to her nervous system, while in the hands of 
the novice there are few operations more repulsive even to the 
uninterested spectator. A small percentage of the amount 
of practice required to make a good marksman, billiard -player, 



278 INTUBATION IN CEO UP AND OTHER 

etc., if expended in the manner above indicated, would impart 
sufficient dexterity to obtain the best results with intubation, 
and at the same time avoid a great deal of unnecessary suffer- 
ing* and some loss of life also. 

The proper time for removing" the tube from the larynx 
will depend on the age of the patient, the character of the dis- 
ease, whether of slow or rapid development, and the progress 
of the case. 

In one hundred and fifty-eight recoveries from croup, in 
which the exact time was recorded, the average retention of 
the tubes amounted to five days and two hours. In my own 
forty-nine recoveries, the longest time a tube was retained 
was fourteen days, and the shortest time in which pseudo- 
membrane was demonstrated to have been present was four- 
teen hours. 

The younger the patient, as a rule, the longer the tube will 
be required. In children under two years of age it is better to 
leave it in seven days. 

When the disease has developed slowly, and has therefore 
run a greater part of its course before calling for operative 
interference, the tube can be dispensed with earlier — sometimes 
as soon as the second or third day. 

If the case be at such a distance as to render it impossible 
to reach it in a reasonable time, it is safer, if progressing fav- 
orably, to leave the tube in position for seven or eight days, 
and the exceptions are few in which it will be necessary to re- 
insert it after this time. 

The tube should always be removed on the recurrence of 
severe dyspnoea, because it is sometimes impossible to ascer- 
tain with certainty whether it be partially obstructed or not. 
The best evidence to the contrary is a good respiratory 
murmur or numerous rales over the lower posterior portion 
of the lungs. Even under these circumstances I have occa- 
sionally found the lumen of the tube seriously encroached 
upon by firmly adherent secretions. 



FORMS OF STENOSIS OF THE LARYNX. 279 

In one case of this kind, complicated with extensive broncho- 
pneumonia to which the dyspnoea was attributed, the tube 
when removed appealed to be completely occluded through its 
whole length, yet an opening must have existed in it some- 
where. Had I found it in this condition on its removal after 
death I would certainly have attributed the fatal result to 
this cause. 

Such cases — and I have seen several similar ones— prove 
that sufficient air to sustain life can be admitted through an ex- 
tremely small opening. The adhesion of tenacious secretions 
to the inside of the tube is more liable to occur in very young 
children, owing to their comparatively feeble power of cough- 
ing, and for the same reason they are more prone to pulmonary 
complications. In older children who are strong and can be 
induced to cough vigorously such accumulations are rare. 
They are also favored by a high temperature, which is usually 
attended with scanty secretion, and particularly if at the same 
time both nostrils are occluded, necessitating mouth breath- 
ing. 

I have never known any serious diminution of the lumen of 
the tube to occur suddenly from secretions. It is a process 
that usually requires at least many hours and sometimes days. 

The development of a high temperature, especially if accom- 
panied with any considerable amount of bronchitis, on the third 
or fourth day, is a sufficient reason for removing the cannula, 
as it can sometimes be permanently dispensed with as early 
as this, and even if left out for only a few hours without urgent 
dyspnoea, is of great benefit, as it affords an opportunity to 
unload the bronchi of secretions by permitting complete closure 
of the glottis and thus giving full effect to the act of cough- 
ing. In those cases that refuse nourishment after intubation 
or that cannot be induced to take a sufficient quantity, it is 
useless to remove the tube for the purpose of feeding, unless it 
have been in long enough to give some reasonable hope that 
its further use will not be necessary, as it is difficult to con- 



280 INTUBATION IN CROUP AND OTHER 

vince children for some time that they can swallow any better 
than before. 

If no dyspnoea recur in half an hour after the extraction of 
the tube, it is safe to leave the patient, if not at too great a 
distance to be reached within two or three hours. 

Accidents and Dangers of Intubation. — The most serious 
of the accidents incident to this operation is apncea from pro- 
longed attempts to introduce the tube. This can be avoided 
only by acquiring- thorough familiarity with the use of the in- 
struments in the manner already pointed out. The beginner, 
unless he possess an unusual amount of coolness, is liable to 
forget that while his finger is in the throat, the patient cannot 
breathe, and that a fatal asphyxia may be produced in a very 
few seconds. Ten seconds is the longest time that should be 
occupied in each attempt, if the child be suffering from urgent 
dyspnoea at the time. If the finger be then removed from the 
mouth, and the patient be given a chance to get its breath, 
many failures to properly place the tube can be made without 
danger. 

The expert seldom requires more than five seconds to com- 
plete the operation, except in difficult cases, such as a very 
small mouth and throat, marked increase in the size of the 
tonsils, especially if chronic, extreme tumefaction of the epi- 
glottis and ary-epiglottic fold which changes or obliterates 
the usual landmarks, and the struggles and resistance some- 
times offered by older children when intractable. In the latter, 
although I have never had to resort to it, the administration 
of an anaesthetic would be less injurious than the exhaustion 
and cyanosis induced by a prolonged struggle without it. 

If the tube has once passed on the outside of the larynx, 
and this is recognized before it is detached from the obturator, 
it is useless to try to rectify the position without first depress- 
ing the handle of the introducer as in the beginning of the 
operation, because owing to the length of the tube the palate 
arrests the upward movement before the distal extremity 
reaches the level of the glottic opening. 



FORMS OF STENOSIS OF THE LARYNX. 281 

In croup the ventricles of the larynx are usually obliterated 
by swelling- of the tissues and covered over by the pseudo- 
membrane, and therefore seldom offer any obstacle to the 
passage of the tube on the first introduction; but when the 
stenosis persists longer than usual and reintroduction becomes 
necessary, it is well to remember that this may be a source of 
obstruction. The tube once having entered a ventricle, a 
moderate amount of force is all that is necessary to make a 
false passage. I have known this accident to occur when the 
operator was unconscious of having used any force whatever. 

If the patient's head be thrown too far back, the tube may 
also be arrested by coming in contact with the anterior wall 
of the larynx or trachea. 

Pushing down membrane before the tube is the most seri- 
ous of the unavoidable accidents attending this operation. 

It has happened in only three of my own two hundred and 
nine cases of croup, so far intubated, on the first introduction. 
In two of these apnoea was complete, and the tubes had to be 
removed immediately and were followed by complete casts of 
the trachea. In the third case expiration only was seriously 
obstructed, and the tube was allowed to- remain about ten 
minutes in order to allow the lungs to become fully inflated, 
and to make more room in the glottis for the passage of the 
pseudo-membranous mass. As traction was made on the 
thread, the patient was directed to cough, and with the same 
result as in the others. 

In none of these cases was the dyspnoea relieved in the 
least by the rejection of the membranes, and the immediate 
reintroduction of the tube was necessary in each. Had the ob- 
struction existed in the trachea, the relief would have been 
prompt, but it w T as in the glottis, where the fibrinous exuda- 
tion remains long adherent and where the principal cause of 
the stenosis is the infiltration of the mucous membrane and 
underlying tissues and not the film of adventitious material 
on the surface. 



282 INTUBATION IN CKOUP AND OTHEE 

The trachea being- so much larger than is required for the 
free passage of air to and from the lungs that no amount of 
fibrinous exudation, however thick, while still adherent, can 
produce serious impediment to respiration, this accident can 
only occur when a cast, or partial cast, lying loose in the 
trachea accumulates before the tube in its downward course, or 
the membrane being adherent above and detached below may 
close around the distal extremity of the tube, and partially or 
completely suspend expiration. I have had three deaths from 
the latter cause in two hundred and nine cases, occurring from 
one to three days after intubation. In two of these the pres- 
ence of membrane below the tube was recognized immediately 
after the operation, but as it did not interfere with respiration 
at the time, the precaution of leaving the string attached was 
not taken, and both children were old enough to render this 
plan feasible. Pushing down pseudo-membrane is more liable 
to occur in cases of slow development, because it has had time 
to become detached, and for the same reason on reintroducing 
the tube after its removal for an} T cause. When not held 
below by processes extending into the bronchi, it is almost 
invariably expelled on again removing the tube. In some 
cases I have succeeded in breaking up such adhesions by in- 
serting a longer tube or by inserting and removing the tube 
several times in succession. 

I have devised and tried several instruments for the re- 
moval of pseudo-membrane from the trachea, which have not 
proved satisfactory. The one shown in the cut (fig. 10) I have 
not yet used. It is introduced closed and expands with a 
spring below and hugs the sides of the trachea while being 
withdrawn. It is of sufficient length to reach to the bifurca- 
tion and therefore much more difficult to insert than a tube. 
Even if completely successful in accomplishing the object in- 
tended, it would be useless, if not dangerous, in the hands of 
any but an expert. Other means of minimizing the danger of 
sudden occlusion of the tube by loose membrane in the lower 



FORMS OF STENOSIS OF THE LARYNX. 



283 



portion of the trachea are available and within the reach of 
all. The most important of these for older children who are 
under control has already been referred to. It consists in 
leaving the string- attached and fastening it behind the ear in 
cases in which the existence of pseudo-membrane below the 
tube is demonstrated, immediately after the operation, by a 
hoarse or croupy quality of the cough or a napping sound with 
respiration or coughing. 

In only one out of several cases in which I resorted to this 
plan during the past year was it necessary for the attendant 
to remove the tube. The patient was seven years old, and 




Fig. 10. 



made no complaint of suffering or annoyance from the string. 
A cast of the trachea had been expelled several days before 
the operation was necessary, and another had formed, its 
presence being manifested not only by the symptoms given 
above, but also by the occasional complete arrest of the escape 
of air during violent expiratory efforts, such as coughing. 
During quiet breathing, neither respiratory act was inter- 
fered with. The patient was warned against touching the 
thread or cutting it with the teeth. The father who acted as 
nurse was directed to watch her closely, and in case of sudden 
choking to pull out the tube. During a fit of coughing in the 
night, sudden dyspnoea developed, the father did as directed, 



284 INTUBATION IN CROUP AND OTHER 

and a cast of the trachea was expelled. The next day the 
tube had to "be reinserted for a short time, hut the patient re- 
covered, having retained the tube in the larynx in all only 
fourteen hours. 

It is difficult to leave the string- attached in young children, 
for if they do not succeed in seizing it with the hands they will 
soon chew it apart. The latter difficulty may be overcome 
when there is room to pass the thread between two of the double 
teeth. When this plan cannot be adopted, a smaller tube than 
the one suitable for the age should be used, which seldom fails 
to be rejected if obstructed. In a child between one and two 
years of age, for example, the No. 2 tube should be removed 
and the smallest one substituted; at six and a half or seven 
years the 5-7 size should be replaced by the 3-4. In the prac- 
tice of this method, the worst that can happen is the rejection 
of the tube when it is not necessary. Should this occur too 
frequently, a larger size would have to be used. In some few 
cases even the proper size for the age as indicated by the scale 
is coughed out so often that a larger one must be inserted. 

Either of these plans should be resorted to in case the 
symptoms of loose membrane in the lower part of the wind- 
pipe, absent at the time of operation, subsequently show them- 
selves. 

In the event of sudden asphyxia, the nurse should be in- 
structed to quickly grasp the child and hold it head down- 
wards, at the same time shaking it vigorously, the weight of 
the tube being sometimes sufficient to displace it. 

The obstruction in the great majority of these cases is to 
expiration only, inspiration being free. Air in excessive quan- 
tity therefore rapidly accumulates in the lungs, and this may 
be used as the expelling power by causing some of it to escape 
suddenly, in imitation of the act of coughing, by a forcible 
blow or slap with the open hand on the front of the chest, at 
the same time preventing the descent of the diaphragm by 
pressure of the other hand on the abdomen. It will be more 



FORMS OF STENOSIS OF THE LARYNX. 285 

likely to succeed if the patient be placed across the knees or 
other hard surface than if practiced on the bed. 

If complete occlusion exists death probably results in less 
than one minute, and whatever is done must be done quickly, 
and by the nurse, as there is no time to summon the physician. 

During- the fit of coughing- that immediately succeeds intu- 
bation, pieces of pseudo-membrane are frequently expelled. 
These are usually only fragments detached from, the chink of 
the glottis or anterior wall of the trachea and carried down 
with the tube, but they sometimes amount to considerable 
masses; even a cylindrical cast almost an inch long I have 
known to be forced through the small opening in one of the 
medium-sized tubes. 

I have never known any serious obstruction to result from 
loose membrane above the tube, but extreme tumefaction of 
the epiglottis and ary-epiglottic folds does in rare cases give 
rise to dangerous constriction at this point. 

In one case I recognized this condition from the noisy ob- 
structed inspiration, and easily detected the overlapping tissues 
by inserting the finger. This difficulty can be overcome by 
coating the head of the tube with several layers of collodion, 
which, if allowed sufficient time to dry, will adhere for a con- 
siderable length of time, or a larger tube can be used. 

Gradual accumulation of tenacious mucus sometimes mixed 
with milk-curd occasionally takes place in the tube and renders 
its removal for the purpose of cleaning necessary. It is more 
liable to occur in those cases that cough but little, also in very 
young children or where there is marked prostration, because 
the expulsive power of the cough under these circumstances is 
slight. For the same reason, when the lumen of the tube has 
been seriously encroached upon in this manner it is seldom 
expelled, as the volume of air admitted at any one time is 
comparatively small. 

Coughing out the tube when it is free from obstruction and 
before the stenosis has been permanently relieved does not 



286 INTUBATION IN CROUP AND OTHER 

often occur when the proper size has been used, and is seldom 
attended with any danger, as the dyspnoea does not return im- 
mediately, except in tbose rare cases in which there is exten- 
sive oedema of the glottis or complete paralysis of the abductor 
muscles of the cords. In either of these conditions, when 
recognized, a larger tube than that suitable for the age should 
be used; or, what is still better, a tube specially constructed for 
the case, with extra large ret aining-s well. This is particularly 
important in paralysis, which is likely to persist for a consid- 
erable length of time, because the retaining power which re- 
sides principally in the vocal cords must be transferred to the 
subglottic division of the larynx. 

The tube is more liable to be expelled in the act of vomit- 
ing than by coughing, as the vocal cords in the latter are con- 
tracted, while in the former the weight of the tube sometimes 
favors its rejection from the position the patient, if permitted, 
is apt to assume, with the head on a level with or lower than 
the body. 

Owing to the difference in the size of the larynx in different 
children of the same age, it is impossible to adjust the tubes 
so that they will be retained under all circumstances while 
clear, and at the same time permit of their rejection when 
suddenly occluded. 

The most serious injury may be done to the larynx in at- 
tempting to remove the tube if the extractor be passed down 
beside instead of into the opening, and it is often impossible 
even for the expert to locate the point of the instrument with 
certainty before separating the blades. It is important there- 
fore to remember that no force whatever is required to remove 
the tube, and that any resistance to the withdrawal of the ex- 
tractor proves that it is caught in the tissues on the outside. 
By forcibly removing the instrument under these circumstances 
I have known sufficient laceration to be produced to allow the 
tube to drop in the trachea, and this is the only way in which 
this accident can occur with the large-headed tubes now in use. 



FORMS OF STENOSIS OF THE LARYNX. 287 

To minimize this danger as far as possible a regulating" 
screw has been added to the extractor, which prevents the 
blades from opening- any wider than is required to hold the 
tube with sufficient firmness to prevent slipping-, and can be 
adjusted to suit the different sizes. Most of the old instru- 
ments are too slight, and therefore too elastic, to render the 
addition of this screw of any service. 

Attention to the following points will enable every one to 
detect the most serious defects found in many of the tubes 
still in the market. 

The head or shoulder which rests in the vestibule of the 
larynx, and which is firmly grasped by the surrounding tis- 
sues during every act of swallowing, should be absolutely free 
from any roughness or sharp edges that would cut into or 
irritate the intensely inflamed mucous membrane. This por- 
tion of the tube — about one-fourth of an inch — has a slight 
backward curve which, if not apparent, can readily be detected 
by placing the anterior edge in contact with any level surface. 
Its object is to give greater freedom to the epiglottis in pre- 
venting the entrance of food during the act of swallowing, 
and to avoid ulceration, which was not an uncommon occur- 
rence with the straight tubes first used. For the same reason 
there is no flange anteriorly, and the metal here is left thick 
enough to prevent the formation of a cutting edge, as the epi- 
glottis is pressed with considerable force on this part with each 
deglutition. Those not familiar with the object of this con- 
sider it a serious defect because occupying room that should be 
devoted to the calibre. The metal on the anterior surface of 
the lower extremity should be even thicker than above, and 
smoothly rounded off so that it will glide up and down over 
the mucous membrane without cutting it. 

The upper extremity of the tube being fixed, is raised with 
the larynx and at the same time pressed backwards by the 
base of the tongue, which pushes the epiglottis before it. This 
lever action brings the distal extremity in contact with the 



288 INTUBATION IN CROUP AND OTHER 

anterior wall of the trachea, and instead of occupying a fixed 
position, as it does above, moves about half an inch in a verti- 
cal direction. The upward movement, coincident with closure 
of the epiglottis while swallowing, is harmless, but the injury 
is inflicted as the tube, still in contact with the mucous 
membrane, returns to what may be called its respiratory posi- 
tion. 

If long worn, even the most perfect tube will produce some 
abrasion of the inflamed and infiltrated tissues at the point 
indicated, from the frequent rubbing, which occurs with every 
act of swallowing, either of saliva or of food, and probably 
amounting to over a hundred times daily. If the tube be 
rough or have a sharp edge at this point, it will inflict serious 
injury on the mucous membrane even to laying bare the carti- 
laginous rings. 

The ulceration thus produced is sometimes the cause of 
dysphagia, and is in all probability the source of the blood 
that occasionally tinges the expectoration several days after 
intubation. 

The retaining-swell protects the sides of the trachea, and 
therefore the metal on the lateral aspects of the distal end 
should be thin in order to leave the entering portion of the 
tube small to facilitate its introduction. 

As the tube seldom impinges on the posterior wail the 
metal at this point need not be so thick as in front, but suffi- 
ciently so to make it blunt and smooth. 

Another very serious defect, and a very common one, is the 
imperfect fitting of the obturator in the tube both above and 
below. If this exist below, it fails to make a perfect probe- 
point and is liable to injure the tissues of the larynx or scrape 
off pseudo-membrane in its downward course. If above, it 
allows the tube to wobble when attached to the introducer, 
and if the operator fail to place it in the larynx on the first 
attempt the tube is certain to slip off, and besides the annoy- 
ance, he is obliged to lose valuable time in readjusting it. This 



FORMS OF STENOSIS OF THE LARYNX. 289 

is even liable to happen in striking- the base of the tongue or 
other part before the larynx is reached. If properly made the 
tube and introducing' instrument, when united and ready for 
use, should be as free from motion as if constructed of one 
piece, and this, owing to the joint in the shank of the obturator 
and the curve in the upper part of the bore of the tube, is diffi- 
cult to obtain. 

I have also noticed that the lines indicating- the years on 
the scale do not always correspond to the length of the tubes, 
rendering it difficult for the beginner to select the proper size. 
By observing the following rule the scale can be dispensed 
with. The smallest tube is suitable for the first year of life, 
the second for the second year, the third from two to four 
years, and the others for two years each. 

No instrument -maker has yet succeeded in constructing 
these tubes properly without repeated instructions and many 
failures. It is therefore not surprising that those who never 
received any instruction whatever should turn out such grossly 
imperfect instruments as are constantly to be found in the 
market. 

Diagnosis of Croup. — Croup, from its characteristic symp- 
toms, should be one of the easiest of all diseases to diagnos- 
ticate, and as a rule it is, but in cases seen for the first time, 
when moribund or nearly so, the cough having ceased and 
nothing remaining but the labored breathing, it is sometimes 
impossible with the imperfect history obtainable from the ex- 
cited parents or friends to differentiate dyspnoea due to this 
disease from that produced by other causes. While doubt 
under such circumstances is justifiable, I know from personal 
experience that mistakes for which there is no excuse are oc- 
casionally made and that would never occur, were a little 
attention paid to the prominent symptoms of croup. 

These symptoms in the order of their importance are the 
following: The peculiar character of the cough, of the breath- 
ing, the hoarseness or aphonia and dyspnoea. The croupy 
19 



290 INTUBATION IN CROUP AND OTHER 

cough may be called a constant and characteristic symptom, 
for the cases in which it is absent with pseudo-membrane in 
the larynx can safely be excluded on their rarity. 

The croupy or noisy breathing- is almost always present, 
but not marked in the early stage of the disease. 

Hoarseness is a very early symptom, and occasionally pre- 
cedes the croupy cough by a considerable length of time. It 
is almost always followed by aphonia or complete loss of voice, 
except with violent effort, when it is usualry possible to pro- 
duce a distinct sound. Aphonia in children should always be 
regarded with grave suspicion, as in rare cases it is the only 
evidence of laryngeal diphtheria ; while, on the other hand, a 
fatal stenosis may exist in the narrow portion of the larynx 
just below the vocal cords without material alteration of the 
voice. It is particularly liable to occur in the ascending cases, 
in which the disease begins in the trachea and sometimes pro- 
duces sufficient infiltration and thickening of the mucous 
membrane of the subglottic region to cause apncea before any 
fibrinous exudation whatever has been thrown out. The cut 
(fig. 6) represents a specimen from a case of this kind. The 
voice, with the exception of weakness toward the end, was 
not altered and no pseudo-membrane existed at the seat of 
greatest constriction. 

Dyspnoea, except that due to spasm which may occur at 
any stage of the diesase, is a late symptom, and is at first 
mainly inspiratory, but later, when the respiration assumes a 
sawing character, both respiratory acts are about equally ob- 
structed, and occasionally the exit of air is more impeded than 
its entrance. In the latter case acute general emphysema is 
the result, with modification of some of the ordinary physical 
signs previously described. 

It may be put down as a general rule that any impediment 
to respiration situated in the larynx or trachea, or produced 
by pressure on these parts from the outside, gives rise to 
greater obstruction to inspiration than to expiration. The re- 



FORMS OF STENOSIS OF THE LARYNX. 291 

verse is also true in several of the respiratory diseases located 
below these points, such as spasmodic asthma, emphysema, 
capillary bronchitis, and the pressure of enlarged bronchial 
giands on or in the immediate vicinity of the bifurcation. In 
two cases of the latter which I have observed and verified, the 
dyspnoea was markedly expiratory or asthmatic, and while it 
is not probable that this always obtains, it is worth remember- 
ing- as an aid to diagnosis in obscure cases. 

The following- diseases are those most commonly mistaken 
for croup, according to my own experience : Naso-pharyngeal 
obstruction from intense tumefaction of the tonsils and other 
tissues at the entrance of the fauces, with co-existing- occlusion 
of the nares. In two out of several such cases seen during 
the past year, all malignant forms of diphtheria, there was 
marked C3^anosis, which disappeared as the swelling subsided 
under the influence of warm, mildly astringent irrigations; but 
all eventually proved fatal from the severity of the disease. 
The noisy breathing simulates that of croup, but the cough 
and voice are unaffected. 

I have seen some cases in which croup complicated this 
condition where it was difficult to determine as to how much 
of the dyspnoea was laryngeal and how much pharyngeal. 
Temporarily conveying the air beyond the pillars of the fauces 
by the insertion of a large catheter or other means would 
under these circumstances be decisive. 

It should be remembered also that with such a degree of 
malignancy, the intense inflammatory oedema of the surround- 
ing tissues may dip into the vestibule of the larynx and 
produce fa fcal stenosis without implicating the cords and be- 
fore pseudo-membrane has had time to form. The introduc- 
tion of an educated finger is the best aid to diagnosis in this 
case. 

To be able to locate the seat of the impediment to respira- 
tion when called upon to intubate, and to decide whether the 
operation, which cannot remove obstruction in the pharynx, 



292 INTUBATION IN CROUP AND OTHER 

be indicated or not, is the only advantage to be derived from 
exact diagnosis in this class of cases, as they always prove 
fatal as far as I have seen. 

Ketro-pharyngeal abscess is more liable to be confounded 
with oedema of the glottis than with croup, for the reason that 
in both inspiration only is obstructed, but deglutition is also 
interfered with in the former. 

Abscess in this location is likely to be overlooked simply 
because being comparatively rare it is not thought of. The 
attention once having been called to it, the diagnosis is easily 
made either by sight or by the sense of touch. The finger 
comes in contact with a soft doughy swelling instead of the 
hard posterior wall of the pharynx. All the cases of retro- 
pharyngeal abscess seen by the author Avere in children under 
two years of age, and some of them were infants only a few 
months old. 

Primary idiopathic oedema of the glottis is one of the 
rarest of diseases in children, and if mistaken for croup is of 
no importance as far as intubation is concerned. 

Paralysis of the abductor muscles of the glottis only ob- 
structs inspiration, and the more forcible this act the more 
closely the cords are approximated. It is almost exclusively 
a sequel of diphtheria, and in young children produces asphyxia 
in a very short time. 

Laryngismus stridulus, or spasm of the glottis, is charac- 
terized by its sudden onset, crowing inspiration, and croupy 
cough. It is only the local manifestation of a general de- 
rangement of the nervous system, and often ends in convul- 
sions. Intubation is sometimes indicated, but the paroxysm 
usually subsides or proves fatal before there is time to sum- 
mon medical aid. Laryngeal porypi are of slow development, 
and affect the voice for a considerable length of time before 
the breathing. 

In cases with obscure history and unusual symptoms it is 
well to remember that various kinds of foreign bodies may 



FORMS OF STENOSIS OF THE LARYNX. 293 

gain admission to the larynx and be retained for some time 
without producing" complete asphyxia. 

There is no possible excuse for any error in diagnosis be- 
tween pulmonary or bronchial affections and croup which I 
have known to be made. 

To differentiate simple catarrhal croup and fibrinous laryn- 
gitis is a matter of little importance as regards intubation, 
because the former rarely endangers life or calls for surgical 
interference, while only a small percentage of the latter re- 
cover without it. False croup usually makes its appearance 
suddenly in the night, followed by marked improvement or 
complete intermission during the day. Fibrinous croup, on 
the contrary, except in fulminant cases, is rather slow and in- 
sidious in its development, but steadily progressive, presenting 
at first only slight hoarseness with croupy cough, and attended 
with little constitutional disturbances, when neither nose nor 
pharynx is involved. A sharp rise of temperature, such as 
104°, points rather to false than true croup. Albuminuria is 
diagnostic of the latter. 

Medical advice is usually sought more promptly in the 
false variety, because it presents more alarming symptoms at 
the outset, than in the fibrinous form, which is often regarded 
with indifference until the breathing has become affected. 

The much -vexed question of the identity or non-identity of 
croup and diphtheria would not be a subject of much practical 
importance, were it not for the fact that many lives are sacri- 
ficed every year on account of the duality theory. When a 
case is once diagnosticated as membranous croup, no precau- 
tions are taken to protect other members of the family, 
because it is not a contagious disease. 

I can safely say that at least one-fourth of all the cases 
that I have been called upon to intubate were regarded as 
simple fibrinous laryngitis by the attending physicians. In 
many instances other children in these families subsequently 
developed diphtheria with fatal results in not a few. 



294 INTUBATION IN CROUP AND OTHER 

When we consider the frequency with which diphtheria 
begins in the air-passages, and the number of physicians — 
which I know from personal experience to be in the majority 
— who still believe in the distinction between membranous and 
diphtheritic croup, the extent of the danger of unrestricted 
intercourse between the sick and the well can be readily 
appreciated. 

While there may be, and probably is, such a disease as acute 
non-specific membranous croup in children, there is not a single 
sign or symptom by which it can be distinguished from diph- 
theria beginning in the glottis. The only plan, therefore, com- 
patible with safety, is to isolate every case in which there is 
even a suspicion that pseudo-membrane may be developing in 
the larynx, and then contradictory opinions may be entertained 
without injury to any one. 

The principal arguments advanced in favor of the duality 
of croup and diphtheria are that in the former the disease is 
confined to the air passages, and is not attended with the 
usual symptoms of the latter, viz. : asthenia, systemic infec- 
tion, glandular enlargements, albuminuria and paralyses. 

Those, on the contrary, who maintain the identity of these 
diseases regard the location or starting-point of the exudation 
as of no importance, and attribute the greater exemption from 
general infection and the absence of glandular enlargements 
to the smaller surface involved and the limited communica- 
tion of the absorbent vessels of the mucous membrane of the 
larynx and trachea with the glands of the neck. 

My own experience has led me to the conclusion that if we 
have a simple fibrinous croup in New York City or vicinity, it 
must be extremely rare. A very small percentage of the cases 
I have seen might have been of this nature, for any evidence 
to the contrary. Most of those so diagnosticated by the at- 
tending physicians were subsequently demonstrated to have 
been diphtheritic in the manner previously pointed out or by 
the presence of a large amount of albumin in the urine, as 









FORMS OF STENOSIS OF THE LARYNX. 295 

there is no reason for the latter complication in simple mem- 
branous laryngitis. 

During- fifteen years' service at the New York Foundling 
Asylum, I have observed that when that institution was free 
from diphtheria it was also free from croup, and that the 
prevalence of the latter always bore a direct proportion to 
that of the former. The same rule has also applied to private 
practice. 

While we have no positive evidence, either clinical or patho- 
logical, that there are two forms of acute membranous laryn- 
gitis in children, yet there are some facts which demonstrate 
that diphtheria has not the exclusive right to produce this 
kind of exudation. Such, for example, is the false membrane 
that sometimes forms on blistered, burned or other wounded 
surfaces, and which has the same gross and microscopical 
appearances as that of diphtheria. Also that which occurs in 
the bronchi in chronic fibrinous bronchitis, which may last for 
months and even j^ears, the duration alone being sufficient to 
exclude any possible connection with diphtheria, unless we 
admit the existence of a chronic form of this disease. 

The following case is of particular interest in this connec- 
tion. A few months ago, I was requested by a physician of 
this city to visit a relative of his who resided in one of the 
neighboring States, with a view to practicing intubation for 
the purpose of getting rid of a tracheal cannula that had been 
retained for some time. The patient was a man about thirty 
years of age, in excellent health, with the exception of the 
laryngeal stenosis. Five months before I saw him he had a 
severe attack of acute laryngitis, following exposure to cold, 
which in the course of two or three days necessitated the per- 
formance of tracheotomy to avert threatened asphyxia. The 
attending physician, in relating the history of the case, fre- 
quently referred to what he called sloughs, that had been 
ejected daily from the beginning of the attack, and were sup- 
posed to have come from the larynx. I requested the patient, 



296 INTUBATION IN CROUP AND OTHER 

if possible, to produce one of the so-called sloughs in my pres- 
ence, which he did after a good deal of effort. I found it to be 
a piece of pseudo-membrane, almost square, and about half an 
inch in diameter, somewhat thinner than that ordinariry found 
in croup. 

I submitted one of these specimens to Dr. YT. P. Northrup, 
pathologist to the New York Foundling Asylum, for micro- 
scopical examination, who pronounced it identical in every 
particular with the fibrinous exudation of diphtheria. 

In the mirror the deposit could be seen about equally dis- 
tributed over both vocal cords and nowhere else. 

When questioned on the subject, the patient denied syphilis, 
because fully convinced that he never had it ; but he had a node 
on the shin at the time, which had been painful at night, and 
this, together with the laryngitis, was the only manifestation 
of the disease that had ever existed. 

Under the influence of mercury and the iodide, the pseudo- 
membrane disappeared in four days, and never returned. 

Making all due allowance for the fact that the inflamma- 
tory trouble in the larynx was syphilitic, the rapid cure of the 
fibrinous element, which had persisted for five months unin- 
fluenced by a variety of local applications, argues forcibly in 
favor of the mercurial treatment of croup. 

This patient was in daily contact with children during the 
whole course of his disease, none of whom suffered from any 
affection of the throat. 

• Prognosis. — Diphtheritic or fibrinous croup without the 
aid of intubation or tracheotomy proves fatal in from 90 to 95 
per cent, of the cases. 

About 10 per cent, of those that I have been called to in- 
tubate finally struggled through without it, and in private 
practice, 27 per cent, with intubation. This makes a total of 
37 per cent., which may be taken as the best results that can 
be obtained in a large number of cases extending over a suffi- 



FORMS OF STENOSIS OF THE LARYNX. 297 

cient period of time to include all types of the disease, mild 
and severe. 

Those who practice either operation early, of course, include 
the cases that would otherwise recover if not interfered with, 
but this does not materially alter the average just given. 

The latest intubation statistics are those compiled by Dr. 
Dillon Brown, who in the month of November, 1888, collected 
2372 cases from 159 operators, with 646 recoveries, or 27.2 per 
cent. 

The age of the patient, the character of the epidemic, the 
origin, nature, and extent of the exudation and the complica- 
tions, are the important factors to be considered in estimating 
the probable termination in any given case. Of these, ag"e is 
by all odds the most important. 

Althougii several recoveries following' intubation for croup 
in children under one year of ag-e have already been reported, 
the percentage is very small. During the second year of life, 
there is a marked improvement in the results, and so on with 
increasing age, until the period of puberty is approached, 
when the statistics so far indicate a falling off in the percent- 
age of recoveries. This may be explained by the fact that the 
liability to croup decreases with age, and that the number of 
older children so far intubated is too limited to warrant any 
conclusion on this subject. Furthermore, owing to the larger 
size of the larynx in these cases, recovery more frequently re- 
sults without operation than in young children, and intubation 
is therefore only called for in the worst forms of the disease. 
For the same reason, when laryngeal diphtheria in the adult 
produces sufficient stenosis to require surgical aid, it indicates 
a malignancy of the disease that is seldom recovered from. 

Croup that prevails during fatal epidemics of pharyngeal 
diphtheria is proportionately fatal and principally from the 
same causes, viz., greater frequency of systemic infection, of 
nephritis, pneumonia, and also greater tendency to invade the 
bronchial tubes. The latter is much more liable to occur when 



298 INTUBATION IN CROUP AND OTHER 

the disease begins in the larynx, than in those cases in which 
the exudation has existed for several days in the fauces, thus 
having run part of its course before invading* the air-passages. 
For this reason the prognosis is less favorable in the so-called 
membranous croup than in the form that is recognized by all 
as diphtheritic. 

Distribution of the pseudo-membrane over a large surface, 
as when with the larynx the nose as well as the fauces is in- 
volved, thick deposit, dark color of the exudation, foul odor, 
great tumefaction of the tissues in the throat and of the 
glands on the outside are unfavorable to recovery. 

Cases with scanty secretion of urine with a perceptible 
amount of blood or large quantity of albumin, such as fifty 
per cent, or over, almost invariably terminate fatally. A 
more copious secretion with the same amount of albumin is of 
less serious import. I have never known albumin to be absent 
in severe cases, but it must be looked for daily, as the urine 
may be free from it one day, and loaded the next. A high 
temperature on the second or third day after intubation is an 
evil omen, because it usually indicates extension of the disease 
to the bronchi, sepsis, or pneumonia or all combined. When 
the laryngeal stenosis has persisted for some time, and is suffi- 
ciently pronounced to call for surgical interference, the tem- 
perature in the great majority of cases is little above the 
normal. This, to some extent, at least, is due to diminished 
oxidation in the tissues from the limited supply of air admitted 
to the lungs, and explains the rapid rise of temperature that 
not unfrequently occurs soon after intubation, and before 
sufficient time has elapsed for the development of any com- 
plication. Fever coming on in this manner is not so liable to 
persist, and does not possess the same prognostic significance 
as when it shows itself one or more days after the operation. 

Children in the neighborhood of four or five years of age 
breathe, in health, about twenty-five times per minute. An 
increase in the number of respirations to forty or more usually 



FORMS OF STENOSIS OF THE LARYNX. 299 

indicates either a narrowing- of the calibre of the bronchi by 
pseudo-membrane or pneumonia, the latter being" a later de- 
velopment. 

Any considerable invasion of the lower air-passages by the 
disease, almost invariably occludes some of the bronchial 
tabes, which is followed by collapse of the corresponding por- 
tions of the lungs, and this, together with the decrease in the 
lumen of the others, sufficiently explains the acceleration of 
the breathing when no pneumonia exists. 

In young children it is not uncommon for the respirations 
under these circumstances to run as high as from eighty to 
one hundred or more per minute. 

Treatment of Croup. — In estimating the value of any 
remedy in the treatment of croup, a disease so fatal under all 
circumstances and attended by so many grave complications, 
it is important to resist the temptation of being influenced by 
the result obtained in a few cases, whether it be favorable or 
otherwise. 

The mortality from diphtheria, and consequently that from 
croup, varies so much in different epidemics, that it is neces- 
sary before arriving at any conclusion not only to observe a 
large number of cases, but also that these should extend over 
a sufficient period of time to include all types of the disease. 

As my own views on the medicinal treatment of diphtheria 
and croup coincide so perfectly with those of the author of 
this work it is only necessary for me to indorse the method 
advocated by Dr. Billington, to which the reader is referred, 
and give some directions for the management of laryngeal 
diphtheria following intubation. 

Of the many therapeutic agents that have been, and are 
still employed in the treatment of croup, I believe the bi- 
chloride of mercury deserves the first place. Very few, if any, 
of those who have used it, after having had sufficient experi- 
ence with other remedies to render their opinion of much 
value, have abandoned its use after a fair trial. 



300 INTUBATION IN CKOUP AND OTHER 

After intubation the same treatment is continued, with the 
exception of an interval of two or three hours following the 
operation, during- which nothing" is given by the mouth, in 
order to allow time for the larynx to become accustomed to 
the presence of the foreign, body. In some cases I have found 
it necessary to administer small doses of whisky or brandy 
undiluted soon after placing a tube in the larynx, for the pur- 
pose of exciting sufficient cough to expel accumulated secre- 
tions and loose membrane, the tube with string attached fail- 
ing to accomplish this. 

With a properly fitting tube in the larynx, the difficulty of 
swallowing is due principally to swollen condition of the epi- 
glottis, which is common in croup. This is demonstrated by 
the fact that in other forms of stenosis in which the epiglottis 
is not involved, the difficulty of deglutition is soon overcome. 

Some of the liquids swallowed undoubtedly gain admission to 
the trachea through the tube, but are promptly expelled by the 
coughing thus excited, and are therefore harmless. But should 
the sensibility be so much blunted that no reflex action follows 
the contact of extraneous matter with the lining membrane of 
the air-passages, there is nothing to prevent the gravitation 
of whatever passes through the tube to the smaller bronchi 
and alveoli. The impaired sensibility in such cases is due to 
some form of toxsemia which precludes any reasonable chance 
of recovery, and it is therefore scarcely worth subjecting the 
patient to the annoyance of feeding by stomach tube. But 
there are some cases that suppress the cough because it is 
painful, and in these the plan of feeding suggested by Dr. Cas- 
tleberry, of Chicago, may be tried. It consists in overcoming 
gravitation by placing the head considerably lower than the 
body, and drinking through a glass tube, nursing bottle, etc., 
which allows any fluid that enters the tube to escape without 
coughing. 

Some patients swallow better by taking a small quantity 
in the mouth at a time, others by filling the mouth. Infants 



FORMS OF STENOSIS OF THE LARYNX. 301 

at the breast swallow better than older children, and most 
cases can drink better from a nursing- bottle than from a cup 
or glass, and on the same principle by sucking through a tube. 
Patients with high temperature, suffering from great thirst, 
will take a long- drink without stopping to cough, although 
the desire to do so be very great. This should not be per- 
mitted, as it gives time for some of the liquid to enter the 
bronchi. The glass should be removed after every two or 
three acts of swallowing, and the child encouraged to cough. 
These precautions do not apply to cases that swallow well, 
which is not uncommon after the tube has remained in the 
larynx for a few days, if the functions of the epiglottis be not 
much impaired. 

Nourishment in the solid and semi-solid forms, which are 
swallowed better than liquids, should be given the preference 
when children can be induced to take them. 

Rectal feeding should be resorted to in case a sufficient 
amount of nutriment cannot be given by the mouth. Warm 
milk with whisky, to which the albumen of one or two eggs 
can be added, is the most convenient for this purpose. Pep- 
tonized milk or the expressed juice of meat is still better. 

The Leube Rosenthal solution of meat, dissolved in warm 
water, is readily absorbed by the rectum if retained long 
enough, as I have demonstrated many times. 

These injections should not be given oftener than once in 
three or four hours, or in larg-er quantities than one or two 
ounces to a child four or five years old, otherwise they are soon 
rejected. When the bowel becomes irritable, tolerance for 
small quantities is sometimes re-established by a large injec- 
tion of warm water; and should this fail, a few drops of lauda- 
num in warm sweet-oil or starch can be injected with a small 
syringe and allowed to remain about three quarters of an 
hour before using the nutrient enema. In this manner the 
bowel can be used many days in succession, and aids wonder- 
fully in sustaining the vital powers until the patient can be 



302 INTUBATION IN CROUP AND OTHER 

induced to take a sufficient quantity of nourishment by the 
mouth. 

Intubation cases are not the only ones that call for rectal 
alimentation. 

It is not uncommon for children suffering from diphtheria 
or scarlet fever to refuse all kinds of nourishment for several 
days in succession, and if compelled to take it or it is given by 
the stomach tube, it is almost immediately rejected. Rectal 
feeding is just as urgently demanded under these circum- 
stances as if the inability to take food were due to a tube in 
the larynx. 

The most fatal of all the complications of croup is un- 
doubtedly the extension of the disease to the lower air-passages, 
or fibrinous bronchitis ; for the prevention of which there is no 
remedy known at present. Mercury, especially the bichloride, 
probably exerts some limiting or controlling power over the 
fibrinous exudation, which would sufficiently explain the more 
favorable results obtained with this than with any other 
remedy. 

Nephritis is often a serious complication, but is usually in 
proportion to the severity of the diphtheria and the amount 
of systemic infection. Thorough disinfection of the absorbing 
surfaces in the throat and nose is therefore an important 
part of the treatment. The improvement in the albuminuria 
goes hand in hand with that of the original disease, and rapid 
recovery follows as soon as the poison is completely eliminated 
from the circulation. 

From the physiological fact that urea is a constant con- 
stituent of normal sweat, and that its quantity is largely in- 
creased when there is a deficient elimination by the kidneys, 
free action of the skin is a rational and valuable means of 
carrying off excrementitious products that would otherwise 
accumulate in the blood and tissues when the function of the 
kidneys is seriously impaired. There is no better method of 
accomplishing free diaphoresis than that necessarily produced 



FORMS OF STENOSIS OF THE LARYNX. 303 

by the steam treatment under a tent. Under these circum- 
stances the temperature of the air immediately surrounding- 
the patient can be kept as high as 80° with advantage. With- 
out the kidney complication, 75° is sufficient. 

The high temperature that usually accompanies the pneu- 
monia, fibrinous bronchitis, and sepsis can, in most cases, be 
kept within bounds by the use of antipyrin or antifebrin com- 
bined with digitalis, which, even if they accomplish nothing in 
the way of saving life, contribute a good deal to the comfort 
of the patient, by allaying the thirst and restlessness produced 
by the fever. 

A sufficient amount of sleep should always be procured, and 
it is much better to give an anodyne for this purpose than to 
allow a child to pass a restless, wakeful night. If due to pain 
or irritation from the tube in the larynx or excessive cough, 
an opiate is the only remedy that will afford relief, otherwise 
sulphonal, in doses of from three to five grains, or a mixture of 
bromide and chloral, will answer the same purpose. . 

Many times in answer to the question whether the little 
patient had obtained any sleep during the night, I have been 
told by the mother that it would have slept, had she not been 
obliged to administer the medicine every half-hour or hour. 

Nervous, irritable children who remain wakeful for some 
time after having been roused to take their dose, should be 
allowed at least three hours of uninterrupted sleep every 
night. From the unsatisfactory results obtained with any of 
the remedies at present within reach, I believe it is much safer 
to temporarily suspend medication than to seriously interfere 
with sleep. 

Intubation in the Adult. — The operator who has acquired 
proficiency in performing intubation in children, will experi- 
ence great difficulty when called upon for the first time to 
operate on the adult. The difference is due to the larger size 
of the larynx in the latter, but particularly to its greater dis- 
tance from the mouth. It is only necessary to reach far 



304 INTUBATION IN CEO UP AND OTHER 

enough behind the epiglottis to hold it erect, and this can 
usually he done by crowding- the finger well back in the right 
angle of the mouth. In one case I failed absolutely, after re- 
peated attempts, to do more than touch the tip of the epiglottis 
without inserting two fingers, which filled the pharynx and 
left no room for the passage of the tube. Intubation was 
finally accomplished in this patient by the aid of the mirror, 
which will probably prove the better plan for those familiar 
with laryngoscopic manipulations. In the latter case it is 
necessary to drop the mirror and quickly insert the finger to 
push the tube home and hold it down while the obturator is 
being removed, for if the thickest portion of the retaining-swell 
be not carried well below the cords, which is often impossible 
while still attached to the introducer, the tube is immediately 
rejected. The removal of the tube from the adult larynx can 
be accomplished with greater ease, and with less discomfort 
to the patient, by guiding the extractor into it by the aid of 
the mirror, than by the finger, as is necessary in children. 
Very little practice with the laryngoscope is required for this 
purpose. 

For any form of acute stenosis of the larynx in the adult, 
two tubes of different sizes, the smaller for the female, the 
larger for the male,. I believe will prove sufficient. But for the 
dilatation of chronic stricture, especially the cicatricial form, 
a set of about ten tubes will be required, and the larger of 
these can be used in acute cases in the adult male, the medium 
sizes in the adult female, and the smallest during the years of 
adolescence. 

A special introducer and extractor, longer and much 
stronger than those used for children, are necessary. 1 

Intubation has already been successfully practiced in almost 
all the different varieties of stenosis that occur in the adult 

Niemann & Co., of this city, is the only firm at present manufact- 
uring tubes and accessory instruments suitable for adults. 



FORMS OF STENOSIS OF THE LARYNX. 305 

larynx, viz.: — Acute oedema of the glottis, erysipelatous in- 
flammation, laryngeal diphtheria, perichondritis, syphilitic 
and tubercular laryngitis, paralysis of the abductor muscles 
of the cords, and temporarily, in neoplasm. 

In cases requiring the retention of a tube for several 
months, it is important to change the points of pressure in the 
vestibule of the larynx about once in two weeks, in order to 
prevent erosion of the mucous membrane, with consequent 
sprouting of fungous granulations, which is liable to occur 
from the compression exerted by the constrictor muscles dur- 
ing every act of swallowing. The larger head that goes with 
the increase in the size of the tubes required for the dilatation 
of the stricture, accomplishes this purpose until the maximum 
size has been reached, when the pressure can be transferred to 
other points by changing the shape of the shoulder of the tube. 
It can, for example, be lifted higher in the larynx by increasing 
the thickness in the vertical direction, having the diameter 
the same. 

A hard-rubber tube may be allowed to remain in the larynx 
for a much longer time than one constructed of metal, because, 
owing to its lightness, it does not occupy a fixed position, but 
moves upward by coughing, and is again pressed downward 
b3^ the act of swallowing. 

Another objection to the long retention of a metallic tube 
is the fact that the gold-plating soon disappears in places, 
followed by erosion of the metal and the deposit of calcareous 
matter, which produces a good deal of irritation. 

I have occasionally found some calcareous granules on 
tubes that were not long retained, and on which the plating 
appeared to have been intact. 

The difficulty of deglutition that follows intubation in 

croup, and that often persists as long as the tube remains in 

the larynx, is not a prominent feature in chronic stenosis. The 

epiglottis being usually in a normal condition, soon learns to 
20 



306 INTUBATION IN CEOUP AND OTHEK 

assume the whole duty of protecting- the larynx, and accom- 
plishes this purpose very perfectly, after a little time, without 
the aid afforded by the constriction of the latter, which, I be- 
lieve, is the more important of the two. 

With a properly fitting- tube, a healthy epiglottis, and free- 
dom from much inflammation or thickening above the vocal 
cords, the difficulty of swallowing at first experienced is usu- 
ally completely overcome in about a week. 

In the treatment of chronic stenosis of the larynx in chil- 
dren, the set of croup tubes will do to begin with, but the cali- 
bre of these is only sufficient for free respiration in a state of 
rest, and therefore not large enough to supply the increased 
demand for oxygen produced by the active exercise that these 
little patients take, which is not materially different from that 
of ordinary health. In the beginning, therefore, when it is only 
possible to pass a small tube through the stricture, it will be 
necessary to restrict the amount of exercise or even confine 
the patient to bed in order to avoid dyspnoea. 

Unlike the conditions present in croup, with its intense 
inflammatory infiltration of the mucous membrane, which 
often leads to spontaneous ulceration, the larynx in these 
cases, aside from the constriction, is usually normal, and the 
same danger of injury from pressure does not exist. Much 
larger tubes, and more nearly cylindrical if required, can there- 
fore be used with perfect safety. 

The length of time required for the dilatation of chronic 
stenosis of the larynx will depend on the degree of constric- 
tion, its cause, and duration. In complete occlusion, atrophied 
muscles and anchylosed joints, the necessary result of sus- 
pended function, render such cases the most unfavorable for 
speedy cure. 

Even a very small opening in the larynx, that allows the 
entrance of some air, which keeps the arytenoids and the mus- 
cles that move them in use, gives a better prospect of recovery 
in a reasonable time. 



FORMS OF STENOSIS OF THE LARYNX. 307 

Cases in which a tracheal cannula has been retained as long- 
as a year or more will usually require dilatation for several 
months to effect a permanent cure. 

Where complete closure of the larynx exists, divulsion 
should be practiced through the tracheal wound from below, 
because owing- to the gradual inclination of the vocal cords 
from the circumference towards the centre in this situation, 
there is no danger of passing- the sound or other instrument 
used anywhere else than in the line of the original opening; 
while if done from above, through the mouth, there can be no 
certainty that the point of the instrument is not in one of the 
ventricles, which it would penetrate with the employment of 
less force than would be required to pass through the cicatri- 
cial tissue uniting the vocal cords. 

In the majority of the cases so far treated by myself and 
others, syphilis, usually in its tertiary form, was the cause of 
the stenosis. 

In two children, one a constriction, the other a complete 
occlusion, the cause was high tracheotomy for croup. The 
operation in both of these cases involved at least the subglottic 
division of the larynx, which is often selected because, being 
less deeply seated, it is more accessible than the trachea. 

In one adult, also, who had worn a tracheal cannula for 
two years, the opening had been made in the cricothyroid 
space, and in another immediately below the cricoid cartilage. 

The lumen of the trachea is large, while that of the larynx 
is comparatively small, and, besides the delicate articular and 
muscular apparatus of the latter is liable to serious injury 
from the irritation of a cannula if long retained. There is 
therefore no excuse for laryngotomy or high tracheotomy, ex- 
cept for the removal of a foreign body or neoplasm, and possi- 
bly when pressed for time in case of threatened asphyxia, as 
these operations are undoubtedly the most frequent cause of 
retained cannulas in croup and other forms of obstruction 
that recover in a short time. 



308 INTUBATION IN CROUP, ETC. 

To insure success in management of chronic stenosis of the 
larynx, some ingenuity and a great deal of patience and per- 
severance are necessary in order to overcome the many diffi- 
culties encountered. No set of instruments, however complete, 
will be sufficient for all cases, no two of which are alike, and 
the construction of tubes adapted to special peculiarities will 
sometimes be required. 



INDEX 



Abercrombie, albuminuria in 
diphtheritic paralysis, 115. 
lesions found in diphtheritic 
paralysis, 67. 
Abscess, retro-pharyngeal, mis- 
taken for croup, 292. 
Accommodation, defective, in 

diphtheritic paralysis, 109. 
Acid, boracic, in the treatment of 
diphtheria, 194. 
carbolic, local use of, 180. 
citric, local use of, 199. 
lactic, as a solvent of false 

membrane, 164. 
salicylic, formula for internal 
administration of, 220. 
local use of, 180. 
sulphurous, internal use of, 
183, 222. 
Aconite, 219. 
Adamson, E., internal uge of 

tincture of iodine, 186. 
Adenitis in diphtheria, treatment 
of, 231. 
in nasal diphtheria, 74. 
in pharyngeal diphtheria, 71. 
prognostic significance of, 142. 
Adult, intubation in the, 303. 
Aerotherapy, antiseptic, 197. 
Aetius Cletus, epidemic of diph- 
theria described by, 5. 
Aetius of Amida, description of 

diphtheria by, 3. 
Afanasieff, V., poisoning by chlo- 
rate of potassium, 191. 
Age, in relation to success of in- 
tubation, 297. 
influencing the occurrence of 
diphtheria, 16. 
Air, communication of diphtheria 

through the. 28. 
Albuminuria, complicating diph- 
theria, 89, 302. 
duration of, 92. 
in diphtheritic paralysis, 115. 



Albuminuria in relation to prog- 
nosis, 91, 298. 
of diphtheria and of scarla- 
tina, differences between, 
92. 
therapeutic indications fur- 
nished by, 234. 
time of occurrence of, 90. 
Alcohol in heart failure, 233. 
in laryngeal diphtheria, 243. 
in the treatment of diphthe- 
ria, 204. 
Alum, local employment of, 161. 
Amaurosis, diphtheritic, 113. 
America, early epidemics of diph- 
theria in, 8. 
Angina, diphtheroid, in scarla- 
tina, 104. 
maligna, 3. 

ulcero-membranous, diagnosis 
of, from diphtheria, 123. 
Animals, diphtheria in, 23 

inoculation experiments on, 
26. . 
Antifebrin, 219, 303. 
Antipyretics in the early stage of 

pharyngeal diphtheria, 218. 
Antipyrin, 219, 303. 
Antiseptic aerotherapy, 197. 
fumigations, 198. 
tracheotomy in the preven- 
tion of bronchial diphthe- 
ria, 249. 
treatment, prophylactic value 
of, 147. 
Antiseptics in the treatment of 

diphtheria, 170. 
Anus, diphtheria of the, 88. 
Appendix, 259. 
Applications, local, 156. 
Apomorphia in laryngeal diph- 
theria, 243. 
Archambault-Reverdy, 159. 
Aretseus of Cappadocia, diphthe- 
ria described by, 2. 



310 



INDEX. 



Aretseus of Cappadocia, on the 
use of caustics, 157. 
recommended the use of alum 
and tannin, 161. 
Articulation, difficult, in diphthe- 
ritic paralysis, 109, 111 
Artificial feeding after intubation, 
301. 
in diphtheritic paralysis, 
256. 
respiration in diphtheritic pa- 
ralysis, 256. 
Asclepiades, 2, 265. 
Asthenia in constitutional poison- 
ing, 76. 
Asthenopia in diphtheritic par- 
alysis, 109. 
Astringents, local employment of, 

161. 
Ataxia, diphtheritic, 110. 
Atomizers for use in the treat- 
ment of laryngeal diptheria, 
238. 
for use in spraying the phar- 
ynx, 216. 
Aubrun, perchloride of iron in 

diptheria, 202. 
Aurelianus, Coelius, description 

of diphtheria by, 3. 
Author's conclusions as to the 
etiology of diphtheria, 43. 
treatment of diphtheria, 210. 
views as to the non-identity 
of croup and diphtheria, 61. 
views as to the primary na- 
ture of diphtheria, 96. 
Auto-inoculation of diphtheria, 
25. 

Babes, bacteriological investiga- 
tions of, 39. 
Bacillus of Klebs and Loeffler, 259. 
Bacteria, absence of, in artifici- 
ally produced pseudo-mem- 
brane, 59. 
aerobic and anerobic, 42. 
in diphtheritic membrane, 31, 

259, 263. 
resistance of the organism to 
invasion by, 171. 
Baillou, epidemic of diphtheria 

described by, 4. 
Barbosa, epidemic of diphtheria 

described by, 5. 
Bard, Samuel, treatise on diph- 
theria by, 9. 
Baruch, S., internal use of oil of 

turpentine, 196. 
Beale, micro-organisms in diph- 
theria, 32. 
Becquerel, 14. 



Beef -tea and alcohol, comparative 

effects of, as stimulants, 206. 
Benzoate of sodium in the treat- 
ment of diphtheria, 190, 222. 
Bernhardt, loss of knee-jerk in 
convalescence from diphtheria, 
114. 
Billroth, micro-organisms in diph- 
theria, 32. 
Birds, diphtheria in, 23. 
Bladder, diphtheria of, 88. 

diphtheritic paralysis of the. 
113. 
Blair, Patrick, epidemic of 

lt croops " described by, 6. 
Blcebaum, employment of galva- 

no-cautery by, 159. 
Blood changes in diphtheria, 62. 

micrococci in the, 32. 
Boissarie quoted by Growers, cases 
of paralysis occurring simul- 
taneously with other cases of 
diphtheria, 118. 
Boldyrew, views of, 47. 
Boracic acid in the treatment of 

diphtheria, 194. 
Borax in the treatment of diph- 
theria, 193. 
Bosse, internal use of oil of tur- 
pentine, 195. 
Bouchut, favorable results from 
the use of nitrate of silver, 
158. 
method of intubation of the 
larynx devised by, 15, 266. 
Boyd, J. M., veratrum viride in 

diphtheria, 209. 
Braddon, L., local use of oil of 

peppermint, 199. 
Brain, changes in, 65. 
Breath, foetor of, in pharyngeal 

diphtheria, 70. 
Breathing in laryngeal diph- 
theria, 82, 84, 290. 
Bree, J., internal use of cyanide 

of mercury, 177. 
Bretonneau, limitations in the 
use of caustics, 157. 
artificial production of pseu- 
do-membrane, 58. 
syringe for nasal use, 226. 
term diphtherite proposed 

by, 1. 
treatises on diphtheria by, 11. 
unsuccessful attempt at inoc- 
ulating animals by, 26. 
use of alum by, 161. 
Bromine in the treatment of diph- 
theria, 184, 196. 
Bronchitis, catarrhal, in diphthe- 
ria, 64. 



INDEX. 



311 



Bronchitis, diphtheritic, 137, 302. 
pseudo-membranous, in diph- 
theria, 64. 
Broncho-pneumonia in diphthe- 
ria, 64. 
Brondel, treatment of diphtheria 

by benzoate of sodium, 190. 
Brown, Dillon, quoted by Jacobi, 
internal use of bichlo- 
ride of mercury, 175. 
reference to bibliography 
on intubation prepared 
by, 266. 
statistics of intubation, 
297. 
Graham, parasiticidal action 
of benzoate of sodium in,, 
diphtheria, 190. 
Lenox, rhinoscopic view of 
posterior nares in naso- 
pharyngeal diphtheria, 134. 
T. Clowes, successful treat- 
ment by, 213. 
Brunton, action of iron, 201. 

advantages of nitrate of sil- 
ver, 159. 
on alcohol, 206. 
Buhl, lesions found in diphthe- 
ritic paralysis, 66. 
tissue infiltration observed 
by, 47. 
Bullard, W. E. , cases treated by, 

211. 
Buzzard, T., the pathology of 
diphtheritic paralysis, 117. 

Cadet de Gassicourt, diphthe- 
ritic paralysis of the heart, 
112. 
heart-clots in diphtheria, 63. 
albuminuria in diphtheria, 
91. 
Caldwell, W. C, local use of 
hydronaphthal with papain, 
200. 
Calomel, fumigations with, 178. 
in the treatment of diphthe- 
ria, 173. 
Cannula, tracheal, 251. 
Carbolic acid, local use of, 180, 

236, 237. 
Cardiac complications, symptoms 
of, 93. 
depressants in the treatment 
of diphtheria, 209. 
Carmichael, quoted by Holt, 

128. 
Carter, E. C, use of bichloride of 

mercury, 175. 
Caselli, A., statistics of trache- 
otomy, 245. 



Castleberry, plan of feeding after 

intubation, 300. 
Casts in the urine, prognostic sig- 
nificance of, 92. 
Catheterization of the larynx, 265. 
Causation of diphtheria, 16, 259. 
Caustics, use of, in diphtheria, 157, 
Cautery, actual, use of, 158. 

galvano-, use of, 159. 
Cells, degenerative metamorpho- 
sis of, in diphtheria, 51. 
Chaff ey, W. C, heart-clots as a 

cause of death, 63. 
Chagin, Gustav, statistics of trach- 
eotomy in infants, 246. 
Chapin, H. D., trypsin as a solv- 
ent of false membrane, 164, 
167. 
Charcot and Vulpian, peripheral 
lesions in diphtheritic paraly- 
sis, 65. 
Chaussier, on catheterization of 

the larynx, 265. 
Cheyne, W. W., antiseptic trach- 
eotomy, 249. 
antiseptic treatment employ- 
ed by, 172. 
Childhood, diphtheria mainly a 

disease of, 16. 
Children, special therapeutic in- 
dications in the case of, 152. 
why diphtheria attacks chief- 
ly, 17. 
Chinoline, local use of, 181, 196. 
Chittenden, R. H., pepsine as a 
solvent of false membrane, 167. 
Chloral in the treatment of diph- 
theria, 187, 222. 
Chlorate of potassium, formula 
for internal administra- 
tion of, 219. 
in the treatment of diph- 
theria, 191. 
poisonous action of, 191. 
Chloride of iron, formula for in- 
ternal administration 
of, 220. 
internal use of, 196, 201. 
limitations to its utility, 
202. 
Chlorine in the treatment of diph- 
theria, 183. 
Cholewa, on the local use of men- 
thol, 199. 
Chomel, epidemic of diphtheria 

described by, 6. 
Cinchona in diphtheria, 233. 
Citric acid, local use of, 199. 
Clark, C. C. P., on the employ- 
ment of Monsel's solution, 161. 
Cleanliness, necessity of, 170. 



312 



INDEX. 



Climate in relation to diphtheria, 

18, 60. 
Clothing, conveyance of the con- 
tagion of diphtheria by, 28. 
disinfection of, 148. 
Coagula in heart and large vessels 

63. 
Coagulation-necrosis, 48. 

caused by temporary cutting 
off of the blood supply, 58. 
Coffee in heart failure, 238. 
Cohnheim, production of coagula- 
tion-necrosis by temporary 
arrest of the circulation, 58. 
Cold, catching, membranous 
croup from, 59. 
favoring attacks of diph- 
theria, 18. 
Colden, Cadwallader, epidemic 

of diphtheria described by, 9. 
Cologne water, pseudo-membrane 
caused by local application of, 
57. 
Comstock, D. C, cases treated by, 

211. 
Congestion, pulmonary, in diph- 
theria, 64. 
Conjunctivitis, diphtheritic, 14. 
symptoms of, 86. 
treatment of, 257. 
Constitutional poisoning from 
concealed nasal or bron- 
chial diphtheria, 99. 
not dependent upon pu- 
trefactive decomposi- 
tion of the false mem- 
brane, 76. 
Constitutional symptoms often 
relieved by local treatment, 102. 
Contagion, occurrence of diph- 
theria by, -24. 
of diphtheria, conveyance of 
by food and drink, 29. 
difference in virulence of, 
in epidemic or sporadic 
and endemic cases, 30. 
nature of, 30. 
retention of, in furniture 
and clothing, 28. 
Convalescence, tonics during, 232. 
Copaiba in the treatment of diph- 
theria, 208. 
Copper sulphate as a caustic in 

diphtheria, 158 
Corbin, J., mercurial fumigations, 

178. 
Cornil and Babes, bacteriological 

investigations, of, 39. 
Corrosive sublimate, formulae for 
the internal administration of, 
221. 



Corrosive sublimate, internal ad- 
ministration of, 175, 241, 
299. 
local use of, 171 f 196. 
Cough after intubation, 276. 

in laryngeal diphtheria, 82, 
83, 289. 
Croup and diphtheria, question 
of identity of, 59, 61, 293. 
catarrhal and membranous, 
differential diagnosis, 136, 
293. 
diagnosis of, 289. 
intubation in, 265. See In- 
tubation, 
membranous and diphtheri- 
tic, differential diagnosis, 137 
prognosis of, 296. 
relation of season to, 60. 
simple membranous, from 

" catching cold," 59. 
treatment of, 299. 

after intubation, 300. 
Croup-kettle, 240. 
Croupal false membrane, 48. 
Croupous inflammation, 49. 

possibility of multiple causes 
for, 42. 
Cubebs in the treatment of diph- 
theria, 208. 
Curtis and Satterthwaite, inocu- 
lation experiments by, 27. 
micro-organisms in diphthe- 
ria, 32. 
Cyanosis in laryngeal diphtheria, 
84. 
an uncertain indication of in- 
tubation, 271. 

Da Costa, local use of thymol, 
199. 
ulcero-membranous angina, 
123. 
Daly, W. H , calomel in the treat- 
ment of diphtheria, 174. 
Dampness favoring attacks of 

diphtheria, 18. 
Darken, E. J., cases treated by, 

211. 
Death in laryngeal diphtheria, 84. 
Deglutition, difficult, after intu- 
bation, 300. 
after intubation, not promi- 
nent feature in adults, 305. 
in diphtheritic paralysis, 109, 

111. 
management of, 256. 
Dejerine, lesions found in diph- 
theritic paralysis, 66. 
Delavan, D. Bryson, anatomy of 
the tonsils, 124. 



INDEX. 



313 



Delavan, D. Bryson, constitu- 
tional infection following nasal 
diphtheria, 99. 
Delirium, prognostic significance 

of, 143. 
Delthil, account of diphtheria in 
animals by, 23. 
turpentine inhalations, 197, 
241. 
Deslandes, 13. 

D'Espine, A., bacteriological in- 
vestigations of, 39. 
parasiticidal action of salicy- 
lic acid, 181. 
Details, necessity of attention to, 

153. 
Diagnosis of croup, 289. 

of diphtheria, 121 et seq. 
Dickinson, J., epidemic of diph- 
theria described by, 8. 
Diet in diphtheria, 223, 232. 
Digitalis in albuminuria with 
ursemic symptoms, 235. 
in fever, 303. 
in heart failure, 233. 
Diphtheria a constitutional dis- 
ease, arguments in support 
of, 97. 
a local disease, arguments in 

support of, 96. 
ages of those attacked by, 16. 
albuminuria in, 89, 302. 
and croup, question of iden- 
tity of, 59, 61, 293. 
and follicular tonsillitis, dif- 
ferential diagnosis, 130. 
and membranous croup, dif- 
ferential diagnosis, 137. 
and membranous pharyngi- 
tis, differential diagnosis, 
123. 
and scarlatina, differential di- 
agnosis, 135. 
bronchial, diagnosis, 137. 

prevention of, by early 

tracheotomy, 249. 
symptoms of, 85. 
treatment, 302. 
cardiac complications, symp- 
toms of, 93. 
classification of, 68. 
climate in relation to, 18. 
communication of, by a bite, 4. 

through the air, 28. 
constitutional, alcohol in the 
treatment of, 205. 
recovery following, 77. 
relapses in, 78. 
signs of approaching 

death in, 77. 
symptoms of, 75. 



Diphtheria, constitutional, treat- 
ment of, 230. 
contagion of, 24. 
convalescence from, 78. 
cutaneous, 89. 

treatment, 258. 
deep, 51. 
definition, 1. 
derivation of term, 1. 
diagnosis, 121 et seq. 
endemic prevalence, insani- 
tary conditions a potent 
factor in, 22. 
epidemics of, in the middle 

ages, 3. 
eruptions in, 94. 
etiology of, 16, 259. 
gangrene in, 81. 
gangrenous, prognosis of, 143. 
histological changes in, 51. 
history, 2. 
in animals, 23. 
incubation of, 44. 
infection of, 24. 
influence of season upon the 

occurrence of, 19. 
inoculation of, 26. 
intestinal, diagnosis of, 137. 

symptoms of, 88. 
laryngeal, diagnosis of, 289. 

emetics in, 242. 

intubation in, 265. See 
Intubation. 

prevention of, 235. 

prognosis of, 296. 

symptoms of, 82. 

terminations of, 84. 

tracheotomy in, 244. 

treatment of, 235, 299. 

treatment of, after intu- 
bation, 300. 
malignant, 79. 
micro-organisms in, 31, 259. 
mortality, statistics of, 139. 
nasal, diagnosis of, 135. 

especially liable to be at- 
tended with constitu- 
tional poisoning, 74. 

prognosis of, 143. 

symptoms, 73. 
nature of contagium of, 30. 
nephritis in, 89. 
of the anus, 88. 
of the digestive tract, expla- 
nation of the rarity of, 97, 
of the ear, symptoms of, 85. 
of the Eustachian tubes, 85. 
of the eye, symptoms of, 86. 

treatment of, 257. 
of the genito-urinary organs, 



314 



INDEX. 



Diphtheria of the mouth, 75. 

of the oesophagus, diagnosis 
of, 137. 
symptoms of, 87. 
of the stomach, diagnosis of, 

137. 
symptoms of, 88. 
of the vulva, 88. 
of wounds, 89. 
paralysis following, 108. 
parenchymatous, 51. 
pathology, 46 et seq. 
pharyngeal, diet in, 223. 
symptoms, 68. 

of catarrhal stage, 69. 
of stage of pseudo- 
membranous forma- 
tion, 70. 
terminations of, 72. 
treatment of early stage 
of, 214. 
of later stage of, 229. 
poison of, 262. 
predisposition, individual, or 

family, to, 18. 
primary nature of, 96. 
prognosis of, 139 et seq. 
prophylaxis of, 145 et seq. 
pulmonary complications, 

symptoms of, 93. 
second attacks of, 18. 
secondary, 104. 

location of pseudo-mem- 
brane in, 107. 
septic, recovery following, 77. 
relapses in, 78. 
signs of approaching 

death in, 77. 
symptoms of, 75. 
superficial. 51, 78. 
symptoms, 68 et seq. 
tonsillar, explanation of fre- 
quency of, 56. 
tracheal, symptoms of, 85. 
transmission of, by direct con- 
tact, 25. 
treatment, 150 et seq. 
two forms of, 35. 
vaginal, 88. 

without a diphthera, improb- 
able, 123. 
Diphtheritic and scarlatinal al- 
buminuria, differences be- 
tween, 92. 
false membrane. See Pseudo- 
membrane, 
inflammation, 50. 
process, mode of extension of, 

54. 
paralysis, 108. See Paraly- 
sis, diphtheritic. 



Diphtheritic sore-throat, a term 

too vaguely applied, 122. 
Diphtheritis, superficial, 51. 
Diplopia in diphtheritic paralysis, 

109. 
Disinfectants, how to use, 148. 

list of necessary, 147. 
Disinfection, efficiency of, in pro- 
phylaxis, 149. 
instructions for, 147, 170. 
Dissault, on catheterization of the 

larynx, 265. 
Donders, paralysis of ciliary 
muscles following diphtheria, 
107. 
Douglas, William, 8. 
Drain-throat, 123. 
Druitt, Robert, perchloride of iron 

in diphtheria, 202. 
Duchenne, use of the faradic cur- 
rent in the dyspnoea of diphthe- 
ritic paralysis, 256. 
Dwellings, insanitary condition 
of, favoring the occurrence of 
diphtheria, 21. 
Dyssesthesia, in diphtheritic par- 
alysis, 110. 
Dyspnoea as an indication for in- 
tubation, 270. 
for the removal of the 
tube after intubation, 
278. 
for tracheotomy, 244. 
from tumefaction of the ton- 
sils, 291. 
in diphtheritic paralysis, 

management of, 256. 
in laryngeal diphtheria, 82, 
84, 290. 



Ear, diphtheria of, symptoms of, 
85. 

Eau-de-Cologne, pseud o-m e m- 
brane caused by local applica- 
tion of, 57. 

Electrical reactions in diphtheri- 
tic paralysis, 114. 

Electricity in diphtheritic paraly- 
sis, 254. 

Emangard, 13. 

Emboli causing infarctions in 
diphtheria, 63. 

Emetics, failure of, in asphyxia, 
243. 
in croup, caution in the use 
of, 242. 

Emmerich, micro-organism de- 
scribed by, 35. 

Emphysema, acute general, some- 
times present in croup, 271. 



INDEX. 



815 



Emphysema, pulmonary, in diph- 
theria, 64. 

Endemic prevalence of diphthe- 
ria, 22. 

Endocarditis not a frequent com- 
plication, 64. 

Engelinann, local use of vinegar, 
199. 

Epidemic occurrence of diphthe- 
ria, 29. 

Epidemics of diphtheria in the 
middle ages, 3. 

Epistaxis in nasal diphtheria, 74. 

Epithelial changes in diphtheria 
51. 

Epithelium, normal, of mouth 
and throat, impermeable by 
bacteria, 56. 

Eruptions, diphtheritic, 94. 

Etiology of diphtheria, 16, 259 

Eucalyptus, vapors of. in the 
treatment of diphtheria, 198. 

Eustachian tubes, diphtheria of, 
85. 

Euthanasia not always afforded 
by tracheotomy, 248. 

Eye, diphtheria of the, 86, 257. 

Fagge, Hilton, membranous 
laryngitis caused by local injury 
57. 
Feeding after intubation, 300. 
artificial, after intubation, 
301. 
in diphtheritic paralysis, 
256. 
error of over-, in diphtheria, 
223, 232. 
Fever as an indication for re- 
moval of the tube' after in- 
tubation, 279. 
in constitutional poisoning, 

76. 
in pharyngeal diphtheria 69, 

71, 79. 
not necessarily a sign of con- 
stitutional infection, 98. 
prognostic significance of, 142. 
treatment of, 218, 303. 
Fieuzal, local use of lemon 
juice, 199. 
Foetor of the breath in pharyn- 
geal diphtheria, 70. 
Food and drink, aversion to, in 
constitutional poisoning, 77. 
contagion of diphtheria con- 
veyed by, 29. 
to be given at regular inter- 
vals, 224. 
Forceps, tracheal, 253. 
Formulae, see under Treatment. 



Fothergill, John, epidemic de- 
scribed by, 6. 

Fowler, Geo. B., calomel in the 
treatment of diphtheria, 174. 

Fox, quoted by Lefferts, spread- 
ing quinsy, 127. 

Fruitnight, J. H., internal use 
of hyposulphite of soda, 183. 

Fumigation of rooms, 148. 

Fumigations, antiseptic, 198. 
mercurial, 178. 

Furniture, retention of the con- 
tagion of diphtheria, in, 28. 

Gag, mouth, in intubation, 266. 
Galvano-cautery, use of, 159. 
Gangrene, occurrence of, in diph- 
theria, 81. 
Gangrenous diphtheria, prognosis 

of, 143. 
Gargling, availability of, 155. 
Garrotillo, 4. 

Gaucher, lesions found in diph- 
theritic paralysis, 67. 
Genito-urinary organs, diphtheria 

of, 88. 
Gerhardt, account of diphtheria 

in animals bv, 23. 
Gibney, quoted by Holt, 126. 
Gifford, H. , on the Marchand solu- 
tion of per-oxide of hydrogen, 
189. 
Glands, swollen, in diphtheria, 
treatment of, 231. 
in nasal diphtheria, 74. 
in pharyngeal diphtheria, 71. 
Glottis, intubation of the, 265. 
See Intubation, 
oedemaof, mistaken for croup, 
292. 
Glycerine, advantage of, in cover- 
ing the acridity of tincture of 
iron, 220. 
Gowers, frequency of diphtheritic 
paralysis, 108. 
on electricity and strychnine 
in diphtheritic paralysis, 
255. 
v. Graefe, diphtheritic conjunc- 
tivitis described by, 14. 
Guelpa, G., irrigation in the 
treatment of diphtheria, 210. 
method of employing irriga- 
tion, 218. 
Guersant, articles on diphtheria 

by, 12. 
Guttmann, G., successful use of 
pilocarpine, 170. 

Haemorrhages in malignant 
diphtheria, 80. 



316 



I^DEX. 



Haig-Brown, quoted by Holt, 126. 
Hanks, H. T., remarks by, 211. 
Hatfield, M. P., use of peroxide of 

hydrogen, 188. 
Health. Department of New York 
Citv, instructions for disin- 
fection, 147, 170. 
statistics of diphtheria, 16, 19, 
139 
Heart, affections of, in diphtheria, 
93. 
changes in diphtheria, 63. 
clots as a cause of death in 

diphtheria, 63. 
diphtheritic paralysis of, 110. 
failure, treatment of, 233, 257. 
Henoch, employment of galvano- 
cautery by, 159. 
mortality of diphtheria, 140. 
Henry, F. P., hypodermic injec- 
tions of bicyanide of mercury, 
178. 
Hepatic lesions in diphtheria, 65. 
Herpetic sore throat, diagnosis of, 

from diphtheria, 123. 
Heslop, 15. 
Hesse, P., local use of bromine, 

184. 
Heubner, O., absence of bacteria 
in artificially produced 
pseudo-membrane, 59. 
production of false membrane 
by temporary arrest of cir- 
culation in the part, 58. 
scarlatinal diphtheria, 106. 
Hiller. local use of bromine, 184. 
Hippocrates, on catheterization 

of the larynx, 265. 
Hirsch, relation of croup to the 

season, 60. 
Histological changes in diphthe- 
ria, 51. 
History of diphtheria, 2. 

of intubation, 265. 
Hoarseness in croup, 290. 
v. Hoffmann- Wellenhoff, bacte- 
riological investigations of, 40. 
Hofmokl, use of peroxide of hy- 
drogen, 188. 
Holt. L. Emmet, croupous tonsil- 
litis, 128. 
follicular tonsillitis and diph- 
theria not related, 126. 
necessity of correct diagnosis 
in estimating the results of 
treatment, 154. 
Home, Francis, treatise on croup 

by, 6. 
Huber, F., bichloride of mercury, 

175, 221. 
Hueter, 27. 



Htillmann, therapeutic value of 

chlorate of potassium, 192. 
Humidity favoring attacks of 

diphtheria, 18. 
Hutton, T. J., use of nitrate of 

silver by, 159. 
Hvdrogen peroxide, local use of, 

188, 222. 
Hydronaphthal, local use of, 200. 

Immunity, temporary, afforded 
by one attack of diphtheria, 18. 
Incubation, period of, 44. 
Indications to be met in the 

treatment of diphtheria, 150. 
Infection, general, mode of pro- 
duction of, 62. 
not necessary to the produc- 
tion of croupous or diph- 
theritic inflammation, 57, 
60. 
occurrence of diphtheria by, 
24. 
Inflammation, croupous, 49. 

diphtheritic, 50. 
Injection, hypodermic, of mer- 
curial salts, 178. 
nasal, fluids for, 228. 
Inoculation, diphtheria com- 
municated by, 26. 
with cultures of Loeffler's ba- 
cillus, 259. 
Insanitary conditions favoring 
the occurrence of diphtheria, 21. 
Internal administration of rem- 
edies, 155. 
Intestines, diphtheria of the, diag- 
nosis of, 137. 
symptoms of, 88. 
diphtheritic paralysis of the, 
113. 
Intubation in croup and other 
acute and chronic forms of 
stenosis of the larynx, 265. 
accidents and dangers of, 280. 
abrasious of mucous mem- 
brane, 288. 
accumulation of tenacious 

mucus, 285. 
contact of tube with the 
anterior wall of the 
larynx or trachea, 281. 
coughing out the tube, 

285. 
false passage, 280. 
passage of extractor beside 

the tube, 286. 
pushing down false mem- 
brane, 281. 
tumefaction of epiglottis and 
aryepiglottic folds, 285. 



INDEX. 



317 



Intubation, ulceration caused by 
the tube, 288. 
caution as to the manner of 
extraction of the tube, 277. 
cough after, 276 
defects in the tubes, 287. 
description of instruments 

for, 266. 
difficulty of deglutition after, 

300. 
feeding after, 300. 
history, 265. 
in chronic stenosis in children, 

306. 
in the adult, 303. 
indications for, 270. 

for removal of the tube, 
278. 
instruments for, 266. 

in adults, 304. 
introduction of the tube, 274. 
method of operation, 272. 
obstruction of the tube, 278. 
practice on larynx of a small 

animal useful, 276. 
removal of obturators, 275. 
statistics of, 297. 
time for performing, 270. 

for removing the tube, 

278. 
required for, 280. 
treatment of croup after, 300. 
withdrawal of the tube, 275. 
Inunctions, mercurial, 177. 
Iodine, use of, in diphtheria, 185, 

222. 
Iodoform, local use of, 186, 222. 
Iodol, 187. 

Ipecacuanha, syrup of, in laryn- 
geal diphtheria, 242. 
Iron, chloride of, formula for in- 
ternal administration 
of, 220. 
internal use of, in the 
treatment of diphthe- 
ria, 196, 201. 
limitations to its utility, 

202. 
local employment of, 162. 
solution of the subsulphate, 
local employment of, 161. 
Irrigation in the treatment of 
diphtheria, 210, 218. 
means of effecting, 156. 
Irritants, topical, in diphtheritic 

paralysis, 256. 
Irritation, necessity of avoiding, 

in the treatment, 152. 
Isolation, efficiency of, in pro- 
phylaxis, 149. 
necessity of, 146. 



Jaborandi, use of, to loosen the 

false membrane, 169. 
Jacobi, A., chloride of iron in 
diphtheria, 203. 

diphtheritic paralysis not the 
result of the same cause in 
every case, 120. 

disadvantages of the employ- 
ment of steam, 164. 

internal use of bichloride of 
mercury, 175. 

inunctions with oleate of mer- 
cury, 178. 

method of treatment advo- 
cated by, 212. 

tolerance of corrosive subli- 
mate by children, 241. 

use of papayotin, 169. 

Keating, local use of tincture of 

iodine, 185. 
Kidd, Percy, lesions found in 

diphtheritic paralysis, 67. 
Kidneys, changes in. 65. 
Klebs and Loeffler, bacillus of, 

259. 
Klebs, micro-organisms in diph- 
theria, 32. 
microsporon diphtheriticum 
of, 35. 
Klingensmith, J. P., large doses 
of calomel in the- treatment of 
diphtheria, 174. 
Knaggs, H. V., internal use of 

sulphur, 182. 
Knee-jerk, loss of, following 

diphtheria, 114. 
Koch, antiseptic action of ben- 
zoate of sodium, 190. 
antiseptic action of lime- 
water, 166. 
bactericidal action of bi- 
chloride of mercury, 171. 
Kotzuski, calomel in the treatment 
of diphtheria, 174. 

Lactic acid as a solvent of false 

membrane, 164. 
Landouzy, influence of age in the 
occurrence of diphtheritic par- 
alysis, 100. 
Laryngeal diphtheria. See Diph- 
theria. 
Laryngismus stridulus, mistaken 

for croup, 292. 
Laryngitis, catarrhal and mem- 
branous, differential diag- 
nosis, 136. 
croupous and diphtheritic, 
differential diagnosis, 137. 



318 



INDEX. 



Laryngitis, membranous, of non- 
specific origin, 57, 60. 
syphilitic, false membrane in, 
295. 
Laryngoscope, use of, in intuba 

tion in the adult, 304. 
Laryngoscopic appearances in 
diphtheritic paralysis of the 
vocal cords, 111. 
Larynx, chronic stenosis of. in 
children, intubation for, £00. 
downward movement of, dur- 
ing inspiration pathogno- 
monic of obstruction, 271. 
extension of membrane to the, 

prevention of, 235. 
intubation of, 265. 
lumen of subglottic division 

of the, 268. 
stenosis of, intubation in, 265. 
Lax, formula for the employ- 
ment of pilocarpine, 170. 
Lefferts, Gfeo. M., follicular ton- 
sillitis, 127. 
Le Gendre, formula for the em- 
ployment of borax, 193. 
local use of iodoform, 186. 
Lemon juice, local use of, 199. 
Lepine, lesions found in diphthe- 
ritic paralysis, 66. 
Letzerich, internal use of benzo- 
ate of sodium, 190. 
tilletia diphtheritica of, 35. 
zygodesmus fuscus of, 31. 
Leyden, lesions found in diphthe- 
ritic paralysis, 66. 
Liblond, local use of resorcine, 182. 
Lime, slacking, for inhalation in 

laryngeal diphtheria, 241. 
Lime-water and carbolic-acid 
spray in laryngeal diphthe- 
ria, 236, 237. 
as a solvent of false mem- 
brane, 164. 
therapeutic value of, in diph- 
theria, 165. 
vapor of, is simply steam, 164. 
Liouville, lesions found in diph- 
theritic paralysis, 66. 
Liquor sodse chloratse, local use of, 
184. 
potassse as a local application, 
166. 
Liver, changes in, in diphtheria, 

65. 
Local applications, 156. 
Local disease, diphtheria prima- 
rily a, 96. 
Locomotor ataxia and diphtheri- 
tic paralysis, differential diag- 
nosis, 138. 



Loeffler, bacillus of, 259. 

Loeffler, Friederich, bacterio- 
logical investigations of, 36. 

Loomis, A. L. , heart-clots in diph- 
theria, 63. 

Lorain and Lepine, lesions found 
in diphtheritic paralysis, 66. 

Lovett and Munro, statistics of 
tracheotomy, 245, 246, 247, 248. 

Lunar caustic, local applications 
of, 157, 159. 

Lungs, affections of, complicating 
diphtheria, 93. 
changes in, in diphtheria, 64. 

Lunin, comparative statistics of 
the results of treatment by va- 
rious remedies, 196. 

McDonnell, R. L., loss of knee- 
jerk in diphtheria, 115. 
Mackenzie, early advocacy of the 
topical use of nitrate of sil- 
ver by, 12. 
use of nitrate of silver intro- 
duced by, 157. 
Mackenzie, Morell, confluent her- 
pes of the throat, 123. 
inadequacy of medical 
treatment alone in 
laryngeal diphtheria, 
244. 
instances of varying 
periods of incubation in 
diphtheria, 44. 
Maingault, diphtheritic paralysis 

described by, 14. 
Malignant diphtheria, 79. 
March and, solution of peroxide of 

hydrogen, 188. 
Mason, local use of permanganate 

of potassium, 188. 
Membrane, false. See Pseudo- 
membrane. 
Mendel, lesions found in diph- 
theritic paralysis, 67. 
Menthol, local use of, 199. 
Mercier, A., choral in the treat- 
ment of diphtheria, 187. 
Mercurial ointment, inunctions of, 

177. 
Mercury, acid nitrate of, as a 
caustic in diphtheria, 158. 
bichloride of, formulae for the 
internal administration 
of, 221. 
in diphtheria, 299. 
in laryngeal diphtheria, 

241. 
local use of, 171, 196. 
biniodide of, 177, 222. 
cyanide of, 171,177, 222. 



INDEX. 



319 



Mercury, fumigations of, 178. 
iodides of, 171. 
mild chloride of, internally, 

173. 
oleateof, inunctions with, 177. 
salts of, fumigations with, 178. 
hypodermic injections of, 

178. 
injurious effects from the 

abuse of, 179. 
internal use of, 173, 222. 
local use of, 171 ,*222. 
may aggravate constitu- 
tional symptoms, 179. 
yellow sulphate of, as an 
emetic in laryngeal diph- 
theria, 242. 
v. Mering, quoted by Seeligmul- 

ler, 192; 
Metschnikoff, destruction of bac- 
teria by the cells, 171. 
Meyer, lesions found in diphthe- 
ritic paralysis, 67. 
Micrococcus of Oertel, 31. 
Micro-organisms in diphtheria, 
31, 259. 
in the blood of diphtheritic 
patients, 32. 
Milk, contagion of diphtheria con- 
veyed by, 29. 
Milk diet in pharyngeal diphthe- 
ria, 223. 
Monsel's solution, local employ- 
ment of, 161. 
Moore, W. O., rarity of ocular 

diphtheria, 87. 
Mott. lesions found in diphtheritic 

paralysis, 67. 
Mouth, diphtheria of the, 75. 
Mouth-gag in intubation, 266. 
Mundie, Gh, ethereal solution of 

iodoform for local use, 187. 
Mufioz, apomorphine in laryngeal 

diphtheria, 243. 
Murray Gibbes, J., eucalyptus 
vapors, 198. 

Nares, cleansing of the, 225. 
Nasal diphtheria, diagnosis of, 135. 
especially liable to be 
attended with constitu- 
tional poisoning, 74. 
prognosis of, 143. 
symptoms, 73. 
treatment of, 224. 
Nature, primary, of diphtheria, 

96. 
Nephritis in diphtheria, 65, 89, 

302. 
Nerve lesions in diphtheritic pa- 
ralysis, 65, 115. 



Neuritis, interstitial, in diphthe- 
ritic paralysis, 116. 
migrans found by Leyden in 

diphtheritic paralysis, 66. 
parenchymatous, in diphthe- 
ritic paralysis, 115. 
Nicati, account of diphtheria in 

animals by, 23. 
Nitrate of silver, local applica- 
tions of, 157, 159. 
Nitric acid as a caustic in diph- 
theria, 158. 
Noel, internal use of borax, 194. 
Northrup, W. P., examination of 

false membrane by, 296. 
Norwood's tincture of veratrum 

viride in diphtheria, 209. 
Nuclei, degenerative metamor- 
phosis of, in diphtheria, 52. 



Oatman, E. L., local use of bi- 
chloride of mercury, 176. 
CVDwyer, Joseph, dose of bichlo- 
ride of mercury in croup, 
241. 
emetics in laryngeal diphthe- 
ria, 242. 
method of intubation of the 

larynx devised by, 15. 
quoted by Jacobi, internal 
use of bichloride of mercury, 
175. 
(Edema in diphtheritic albumi- 
nuria, 92. 
of the glottis mistaken for 
croup, 292. 
Oertel, M. J., artificial production 
of false membrane, 58. 
bacteriological investigations 

of, 40. 
histological changes in diph- 
theria, 51. 
inoculation experiments by, 

27. 
lesions found in diphtheritic 

paralysis, 66. 
micrococcus of, 31. 
warm vapor recommended 
by, 163. 
(Esophageal diphtheria, diagno- 
sis of, 137. 
explanation of rarity of, 98. 
symptoms of, 87. 
usually secondary, 107. 
Ory, formula for local applica- 
tions of salicylic acid, 181. 
Otitis media, diphtheritic. 85. 
Oxygen in the treatment of diph- 
theria, 188 
Ozone, inhalations of, 189. 



320 



INDEX. 



Pain in pharyngeal diphtheria, 

70. 
Palate, soft, diphtheria of, 68. 

paralysis of, 108. 
Papayotin as a solvent of false 

membrane, 168, 200. 
Paralysis, acute atrophic and 
diphtheritic, differential 
diagnosis, 138. 
beginning in the extremities 
after cutaneous diphtheria, 
116. 
cardiac, treatment of, 257. 
diphtheritic, 108. 

albuminuria in, 115. 
causation of, 117. 
diagnosis of, 138. 
disturbances of vision in, 

109. 
duration, 108-114. 
early, mention of, 5 et seq. 
electricity in, 254. 
experimental production 

of, 261. 
involving the extremities, 

110. 
nerve lesions in, 115. 
of special senses, 113. 
of the bladder, 113. 
of the heart, 110. 

treatment of, 257. 
of the intestines, 113. 
of the larynx, 110. 
of the muscles of the neck 

and trunk, 111. 
pathology, 65, 115. 
post-mortem changes in 

65. 
prognosis of, 144. 
strychnine in, 255. 
symptoms, 108. 
tendency to spontaneous 

recovery, 254. 
treatment, 254, 
Pathology of diphtheria, 46 et 

seq. 
Paulinua, account of diphtheria 

in animals by, 24. 
Pepper, W., internal use of bi- 
chloride of mercury, 175. 
Peppermint, oil of, local use of, 

199. 
Pepsin as a solvent of false mem- 
brane, 166. 
Permanganate of potassium, local 

use of, 188. 
Peroxide of hydrogen, local use 

of, 188-222. 
Pharyngeal diphtheria, mild or 
benign form, symptoms 
of, 72. 



Pharyngeal diphtheria, severe 

form, symptoms of, 72. 

symptoms in stage of 

p s e u d o in e m b r a n ous 

formation, 70. 

symptoms of catarrhal 

stage, 69. 
terminations of, 72. 
treatment of, 214, 229. 
Pharynx and soft palate, diph- 
theria of, symptoms, 68. 
Pierret, lesions found in diph- 
theritic paralysis, 66. 
Pilocarpine, use of, 169. 
Pitres, lesions found in diphthe- 
ritic paralysis, 67. 
Plenio, statistics of tracheotomy, 
245. 
use of iodoform in diphthe- 
ritic invasion of the trache- 
otomy wound, 187. 
Pneumonia in diphtheria, 64. 
Poison, diphtheritic, 262. 

channels of absorption of, 
62. 
Potash, caustic, local use of, in 

diphtheria, 158. 
Potassium, chlorate, formula for 
internal administration 
of, 219. 
in the treatment of diph- 
theria, 191. 
poisoning by, 191. 
permanganate, local use of, 
188. 
Poultry, diphtheria in, 23. 
Powell, Seneca D., inhalations of 

ozone in diphtheria, 190. 
Predisposition, individual or fam- 
ily, to diphtheria, 18. 
Primary nature of diphtheria, 96. 
Prognosis of diphtheria, 139 etseq. 
Prophylaxis of diphtheria, 145 
et seq. 
of laryngeal diphtheria, 235. 
Prudden, T. M. , action of carbolic 
acid in inflammatory con- 
ditions ,180. 
etiology of diphtheria, 263. 
Pseudo-membrane, agents used 
for the destruction of, 162. 
artificial production of, in an- 
imals, 58. 
croupal, 48. 
diphtheritic, 49. 
diphtheritic, appearance of, 

70. 
description of, 46. 
distribution of, 69. 
extraction of, from the tra- 
chea, 282. 



INDEX. 



321 



Pseudo-membrane, formation of, 

through coagulation-necro 

sis, 48. 

in ''croupous tonsillitis, 1 ' 128. 

in syphilitic laryngitis, 296. 

necessity of removal of, in 

nasal diphtheria, 225. 
production of, 46. 

as a result of local injury, 

57. 
by temporary cutting off 
of blood supply, 58. 
pushed down by tube in in- 
tubation, 287. 
solvents of, 163. 
the pathognomonic sign of 
diphtheria, 123. 
Ptomaines, action of, 41, 117. 
Pulse in constitutional poisoning, 
76. 
in pharyngeal diphtheria, 69, 

71. 
prognostic significance of, 143. 
Purpura hemorrhagica in diph- 
theria, 80,. 95. 
prognostic significance of 
143. 



Quinine in the later stages of 
diphtheria, 233. 
in the treatment of diphthe- 
ria, 204. 
seldom useful as an antipy- 
retic in diphtheria, 219. 
Quinoline in the treatment of 

diphtheria, 181, 196. 
Quinsy, spreading, 127. 

Rachford, B. K.,42. 

Ranke, H., statistics of tracheot- 
omy, 245. 

Reactions, electrical, in diphthe- 
ritic paralysis, 114. 

Rectum, feeding by the, 224, 301. 

Reed, unusual order of occurrence 
of diphtheritic paralysis, 113. 

Reflex, patellar tendon, loss of, 
following diphtheria. 114. 

Reinard on strychnine in diph- 
theritic paralysis, 255. 

Relapses, 78. 

Remedies, modes of employing, 
155. 
to be given at regular inter- 
vals, 224. 

Renault, P., rapid tracheotomy, 
252. 

Renou, method of antiseptic 
serotherapy, 198. 

Resorcine, local use of, 182,196. 
21 



Respiration, artificial, in diphthe- 
ritic paralysis, 256. 
character of, in laryngeal 
diphtheria, 82, 84, 290. 
Rhinoscopic view of posterior 
nares in naso-pharyngeal diph- 
theria, 134. 
Rindfleisch, 34, 48. 
Robinson, A. R., quoted by J. 

Lewis Smith, 247. 
Robinson, Beverly, heart-clots as 

a cause of death, 63. 
Rockwell, A. D., 112, 254. 
Roese's treatment of diphtheria, 

195. 
Roser, antiseptic tampon of the 
trachea, 249. 
dislodgment of false mem- 
brane below the trachea 
tube, 253. 
Rossbach, use of papayotin 

locally, 169. 
Rothe, C. Gr., internal use of binio- 

dide of mercury, 177. 
Roux, E., and Yersin, A., on the 

etiology of diphtheria, 259. 
Rural districts, greater fatality of 
diphtheria in, 21. 



Salicylate of sodium as an anti- 
pyretic, 218. 
Salicylic acid, formula for inter- 
nal administration of, 
220. 
local use of, 180. 
Salter, J. H.,29. 

Sanne, alleged analogy between 

diphtheria and syphilis, 103. 

cubebs in the treatment of 

diphtheria, 209. 
diphtheritic eruptions, 94. 
frequency of albuminuria, 90. 
diphtheritic paralysis, 180, 
heart-clots in diphtheria, 
63. 
isthmus of the thyroid, 251. 
mortality of diphtheria fol- 
lowing measles, 107. 
diphtheritic albuminuria, 
91. 
proportion of recovery, with- 
out operation, in croup, 244. 
rapid tracheotomy, 252. 
relation of season to the re- 
sults of tracheotomy, 247. 
statistics of tracheotomy, 246. 
views of, as to the primary 
nature of diphtheria, 97, 99. 
Satlow, internal use of oil of tur- 
pentine, 195. 



322 



INDEX. 



Satterthwaite, 27, 32. 
Scarlatina and diphtheria, differ- 
ential diagnosis, 135. 
diphtheria secondary to, 104. 
nature of pseudo-membrane 
in, 104. 
Schmiedler, local use of oil of tur- 
pentine, 195. 
Schiiler, comparative effects of 
chlorate of potassium, carbolic 
acid and salicylic acid, 181. 
Season in relation to croup, 60 . 
to diphtheria, 19. 
to the results of trache- 
otomy, 246. 
Secondary diphtheria, 104. 
See, Germain, 14, 25. 
Seeligmuller, H., chlorate of po- 
tassium, 192. 
electricity in diphtheritic par- 
alysis, 255. 
Seifert, O., use of chinoline, 181. 
Selden, EL, use of cyanide of mer- 
cury, 177. 
Senator, 32. 

Sensory disturbances in diphthe- 
ritic paralysis, 110. 
Settegast, statistics of tracheoto- 
my, 246. 
Severino, 5. 
Sgambatus, 5. 
Shirres. George, use of iodoform 

after tracheotomy, 186. 
Sigel, A., internal use of oil of 

turpentine, 195. 
Silver nitrate, local applications 

of, 157, 159. 
Simon, Jules, method of local 

treatment of diphtheria, 199. 
Skin, diphtheria of the, 89, 258. 
eruptions on the, in diphthe- 
ria, 94. 
Sleep, necessity of, 303. 
Smith, A., 15. 
Smith, A. H., examination of 

author's cases by, 212. 
Smith, J. Lewis, action of 
ptomaines in the prod- 
uction of diphtheritic 
paralysis, 119. 
addition of liquor potassse 
to lime - water recom- 
mended by, 166. 
condition of the patient as 
affecting the results of 
tracheotomy, 247. 
efficiency of lime-water 
not destroyed by car- 
bonic acid, 165. 
experience with alcohol as 
a stimulant, 207. 



Smith, J. Lewis, influence of al- 
buminuria upon the 
mortality from diphthe- 
ria, 92. 
follicular tonsillitis and 
diphtheria not related, 
126. 
frequency of albuminaria, 
90. 
Smith, S. W., syringe for nasal 

use, 226. 
Snow, H. L., internal use of sul- 
phurous acid, 183. 
Sodium benzoate in the treatment 
of diphtheria, 190, 222. 
biborate in the treatment of 

diphtheria, 193. 
bicarbonate, local application 

of, 166. 
hyposulphite, internal use of, 

'183, 222. 
salicylate, as an antipyretic, 
218. 
Soil in relation to diphtheria, 20. 
Solis-Cohen, J., herpetic sore- 
throat, 123. 
on the local employment of 
chloride of iron, 162. 
Solis-Cohen, S., drain-throat, 123. 
Sore throat, common membra- 
nous, diagnosis of, from diph- 
theria, 123. 
Spain, great epidemic of diphthe- 
ria in, 4. 
Spalding, G. A., quoted by Holt, 

126. 
Specifics in the treatment of diph- 
theria, 208. 
Spinal cord, lesions of, in diph- 

ritic paralysis, 66. 
Spleen, changes in, 65. 
Spray, antiseptic, in the preven- 
tion of laryngeal involve- 
ment, 236. 
method of application in la- 
ryngeal diphtheria, 238. 
Spraying, advantages of, 155. 
Sprays in the treatment of diph- 
theria, 215. 
Squills, syrup of, in laryngeal 

diphtheria, 242. 
Starr, epidemic of diphtheria de^ 

scribed by, 6. 
Statistics, comparative, of the re- 
sults of treatment by bi- 
chloride of mercury, chlor- 
ide of iron, chinoline, resor- 
cin, bromine, and turpen- 
tine, 196. 
mortality of diphtheria, 91, 
139. 



INDEX. 



323 



Statistics of diphtheria in regard 
to age of occurrence, 16. 
of diphtheria in regard to 

season, 19. 
of intubation, 297. 
of tracheotomy, 245. 
Steam, inhalations of, for loosen- 
ing the false membrane, 163. 
in laryngeal diphtheria, 239. 
Steam-atomizer, 239. 
Stenosis of the larvnx, intubation 

in, 265. 
Steudener, views of, 47. 
Stimulants, alcoholic, in diphthe- 
ria, 204. 
in heart-failure, 233. 
in laryngeal diphtheria, 
243. 
Stohr, Ph., peculiarity of the ton- 
sillar epithelium, 56. 
Stomach, diphtheria of, diagnosis, 
137. 
symptoms of, 88. 
usually secondary, 107. 
Strabismus in diphtheritic par- 
alysis, 109. 
Streptococci in diphtheria, 36, 

264. 
Strychnine in diphtheritic par- 
alysis, 255. 
in the later stage of diphthe- 
ria, 233. 
Stumpf, J., use of bichloride of 

mercury, 176. 
Sulphur, employment of, 182, 222. 

fumigation with, 148. 
Sulphurous acid, internal use of, 

183, 222. 
Symptoms, 68 et seq. 
Syphilis and diphtheria, alleged 

analogy between, 103. 
Syphilitic laryngitis, false mem- 
brane in, 295. 
stenosis of the larynx in chil- 
dren, 307. 
Syringe for nasal use, 227. 
Syringing the nares, method of, 
225. 

Tactile sensation, disturbances 
of, in diphtheritic paralysis, 
110. 

Talamon, micro-organism de- 
scribed by, 35. 

Tannin, local employment of, 161. 

Tedeschi, employment of galvano- 
cautery by, 159. 

Temperature in constitutional 
poisoning, 76. 
in pharyngeal diphtheria, 69, 

71, 79: 



Tendon reflex, patellar, loss of, 

following diphtheria, 114. 
Therapeutics of diphtheria, 150 

etseq. 
Thomson, W. H., action of 
ptomaines in the produc- 
tion of diphtheritic paraly- 
sis, 118. 
management of dyspnoea in 

diphtheritic paralysis, 256. 
on the treatment of diphthe- 
ritic paralysis, 256. 
use of bromine in diphtheria, 
184. 
Throat, confluent herpes of the, 
diagnosis of, from diphthe- 
ria, 121. 
inspection of the, in a case of 
suspected diphtheria, 121. 
Thursfield, K M., 16, 20. 
Thymol, local use of, 199. 
Thromboses, venous, in diphthe- 
ria, 63. 
Tonics in the later stage of diph- 
theria, 232. 
Tonsillar diphtheria, explana- 
tion of frequency of, 56. 
Tonsillitis, acute follicular or lac- 
unal, 124. 
diagnosis of, from diphtheria, 

130. 
croupous, 128. 

follicular, contagiousness of, 
124. 
Tonsils, frequency of diphtheria 
of the, 68. 
openings in the epithelium 

covering the, 56. 
tumefaction of, mistaken for 
croup, 291. 
Trachea, antiseptic tampon of 
the, 249. 
extraction of false membrane 

from, 282. 
lumen of, compared with that 
of larynx, 269. 
Tracheal diphtheria, symptoms 
of, 85. 
tube, 251. 
Tracheotomy, 244. 

after-treatment, 252. 
antiseptic, in the prevention 
of bronchial diphtheria, 249. 
conditions affecting the re- 
sults of , 245. 
early, advantages of, 248. 
operation of, 250. 
rapid operation, 252. 
statistics of, 245. 
Treatment, 150 et seq. 
actual cautery, 158. 



324: 



INDEX. 



Treatment, agents for the destruc- 
tion of false membrane, 162. 
alcohol, 204, 233, 243. 
alum, 161. 
antifebrin, 219, 303. 
antipyretics in the early stage 
of pharyngeal diphtheria, 
218. 
antipyrin, 219, 303. 
antiseptic serotherapy, 197. 
antiseptics, 147, 170. 
astringents, 161. 
author's method of, 210. 
benzoate of sodium, 190, 222. 
bichloride of mercury, 171, 

175, 196, 221, 241, 299. 
boracic acid, 194. 
borax, 193. 

bromine, locally, 184, 196. 
calomel, 173, 178. 
carbolic acid, locally, 180, 236. 
cardiac depressants, 209. 
caustics, 157. 

chinoline, locally, 181, 196. 
chloral, 187, 222. 
chlorate of potassium, 191, 219. 
chloride of iron, 162, 196, 201, 

220. 
chlorine, locally, 183. 
citric acid, locally, 199. 
coffee, 233. 
copaiba, 208. 
copper sulphate, 158. 
cubebs, 208. 
disinfectants, 147. 
emetics, 242. 
eucalyptus vapors, 198. 
Formula : 

antiseptic fumigations, 198. 
benzoate of sodium solution 

for internal use, 190. 
bicyanide of mercury for 

hypodermic use, 178. 
biniodide of mercury for in- 
ternal use, 177. 
borax, chlorate of potassium 
and carbolic acid, for local 
use, 193. 
bromine solution for local 

use, 184. 
bromine solution (Lawrence 

Smith's), 185. 
carbolic acid and lime-water 

spray, 215. 
chinoline solution for local 

use, 182. 
chlorate of potassiuni mixt- 
ure, 219. 
chloride of iron mixture, 220. 
corrosive sublimate for in- 
ternal administration, 221. 



Formulae : 

cyanide of mercury for in- 
ternal use, 177. 
hydronaphthal with papain 

for local use, 200. 
iodine, chloride of iron, and 
carbolic acid, for local use, 
185. 
iodoform solution for local 

use, 186. 
papayotin solution for local 

use, 169. 
pepsin solution for local ap- 
plication, 167. 
pilocarpine solution for in- 
ternal use, 170. 
salicylic acid and sulphite of 
soda mixture, 220. 
solution for local use, 181. 
sulphur mixture for internal 

use, 183. 
thymol gaEgle or spray, 199. 
trypsin solution for local 
application, 168. 
fumigations, antiseptic, 198. 

mercurial, 178. 
galvano-cautery, 159. 
general principles of, 151. 
hypodermic injection of mer- 
curial salts, 178. 
hyposulphite of soda, inter- 
nally, 183. 
indications to be used in the, 

150. 
inhalations, 197. 
intubation, 265. 
inunctions, mercurial, 177. 
iodoform, locally, 186, 222. 
iodol, locally, 187. 
iron, chloride of, 162, 196, 201, 

220. 
irrigation, 210, 218. 
jaborandi, 169 
lactic acid, locally, 164. 
lemon-juice, locally, 199. 
lime-water, locally, 164, 236. 
local applications, 156. 
menthol, locally, 199. 
mercury, salts of, 171, 173, 178, 

222. 
modes of employing remedies, 

155. 
of adenitis in diphtheria, 

231. 
of constitutional diphtheria, 

230. 
of diphtheritic paralysis, 254. 
of heart-failure, 233. 
of laryngeal diphtheria, 235. 

299. 
Of nasal diphtheria, 224. 



INDEX. 



325 



Treatment of pharyngeal diph- 
theria, early stage, 214. 
later stage, 229. 

oil ol peppermint locally, 199. 

oil of turpentine, 194. 

oxygen, 188. 

ozone inhalation, 189. 

papayotin, locally, 168, 237. 

pepsin, locally, 166. 

permanganate of potassium, 
locally, 188. 

peroxide of hydrogen, 188, 
222. 

pilocarpine, 169. 

prophylactic, of laryngeal 
diphtheria, 235. 

quinine, 204, 219, 233. 

resorcine, 182, 196. 

results of, 153. 

salicylate of sodium, 218. 

salicylic acid, 180, 220. 

special indications to be met 
in the case of children, 152. 

specifics, 208. 

sprays, 155, 215, 236, 238. 

steam inhalations, 163, 239. 

sulphur, 182, 222. 

thymol, local use of, 199. 

tracheotomy, 244. 

trypsin, 167, 237. 

turpentine, 194, 197, 222, 241. 

turpeth mineral, 242. 

vapor, 163, 197, 238. 

veratrum viride, 209. 

vinegar, locally, 199. 
Trendelenberg, 26, 32, 58. 
Trideau, cubebs and copaiba in 

diphtheria, 208. 
Trousseau, oedema in diphtheritic 
albuminuria, 92. 

on the advantages of early 
tracheotomy, 248. 

paralysis beginning in the ex- 
tremities after cutaneous 
diphtheria, 116. 

term diphtherie suggested 
by, 1. 

unsuccessful attempt at inoc- 
ulation by, 26. 

use of actual cautery by, 158. 

use of alum and tannin by, 
161. ^ 

views concerning the prog- 
nostic significance of albu- 
minuria, 92. 

writings on diphtheria by, 13. 
Trousseau's tracheal dilator, 251. 

tracheal forceps, 253. 
Trypsin as a solvent of false mem- 
brane, 167. 

in laryngeal diphtheria, 237. 



Turpentine, applicable rather to 
laryngeal than to pharyn- 
geal diphtheria, 222. 
in the treatment of diphthe- 
ria, 194. 
inhalations, 197. 
vapor in laryngeal diphthe- 
ria, 241. 
Turpeth mineral in laryngeal 
diphtheria, 242. 

Uremic poisoning, treatment of, 

234. 
Urine, albumin in, in diphtheria, 

89. 

Vagina, diphtheria of, 88. 

Van Wier, 4. 

Vapor, warm, use of, for loosening 

the false membrane, 163. 
Vaporization, advantages of, 156. 
Vaporizing atomizers, 238. 
Vapors, antiseptic, in the treat- 
ment of diphtheria, 197. 
Velpeau, 158. 
Veratrum viride in the treatment 

of diphtheria, 209. 
Villa Real, 4. 
Vinegar, local use of, 199. 
Virchow, classification of false 
membranes, 48. 
forms of inflammation of mu- 
~ cous membranes anatomi- 
cally distinguished by, 14. 
views of, concerning the non- 
identity of diphtheria and 
croup, 61. 
Vogelsang, local use of peroxide 

of hydrogen, 188. 
Voice, character of, in croup, 290. 
in diphtheritic paralysis, 108, 

111. 
in laryngeal diphtheria, 82, 83. 
Vomiting in pharyngeal diph- 
theria, 70. 
prognostic significance of, 142. 
Vulva, diphtheria of , 88. 

Wade, W. F., discovery of the 
occurrence of albuminuria with 
diphtheria by, 14. 
Wagner, E., views of, concerning 
the nature of false membrane, 
46. 
Waxham, F. E., method of intu- 
bating, 275. 
relative efficacy of different 
solvents of false membrane, 
164. 
Weigert, artificial production of 
false membrane, 58. 



326 



INDEX. 



Weigert, views of, concerning the 
production of false membrane, 
47. 
"Werner, P., internal use of bi- 
chloride of mercury, 176. 
"White, W. T., examination of 

author's cases by, 212. 
"Winters, J. E., abuse of mercuri- 
als in the treatment of diph- 
theria, 179. 
on the dose of chloride of iron, 
203. 
Wood and Formad, account of 
diphtheria in animals 
by, 23. 
artificial production of 

false membrane, 58. 
conclusions of, concern- 
ing micro-organisms in 
diphtheria, 32. 



Wood and Formad, inoculation- 
experiments by, 27, 30. 
Wounds, diphtheria of, 89. 
Wyeth, J. A., on tracheotomy, 

251. 



Ziegkler, location of the pseudo- 
membrane, in secondary 
diphtheria, 107. 
mode of formation of false 
membrane, 49. 
v. Ziemssen, electrical reactions 
in diphtheritic paralysis, 
114. 
explanation of the rarity of 
oesophageal inflammation, 
98. 
Zooglea, in diphtheritic mem- 
brane, 32. 



